Shared decision-making empowers both patients and providers, ensuring informed breast cancer surgery choices through open dialogue in treatment planning.
Judy C. Boughey, M.D.
President, American Society of Breast Surgeons
Can you explain what shared decision-making means in the context of breast cancer surgery and why it’s so important for both patients and providers?
Shared decision-making is the collaborative process where the patient and their healthcare providers work together to make decisions for the patient’s care. When you think about a lot of aspects of medicine, in particular surgery, there’s often one clear best recommendation, but I think what is unique about breast surgery is that there are often many options that the patient can have that have a similar cancer outcome. For breast surgery decision-making, shared decision-making is critical.
If a patient comes in with a devastating diagnosis and there’s really only one operation for them, that’s a pretty straightforward conversation. When the patient comes in with a breast cancer diagnosis, there are often at least two options for them — and within those two options, multiple additional options. It really comes down to a shared discussion between the patient and the physician.
This shared decision-making is a back-and-forth discussion between the patient and the provider to discuss the pros and cons of each approach. It’s important for the physician team to listen to the priorities of the patient. For most patients, the first priority is to, of course, get rid of the cancer and treat it appropriately, but what are the other priorities? Is it the time away from work? Is it maintaining their own breast? Is it symmetry? Is it finances? Is it fear of radiation? Hearing all the aspects that are concerning to the patient is important so that the patient and the physician can come up with a treatment that is the most appropriate for them, together.
Can you talk a little bit more about treating breast cancer from a surgical standpoint?
The first key decision that many patients have is breast-conserving surgery versus a full mastectomy. Patients who have extremely large tumors may not be a candidate for breast-conserving surgery, but for many patients these days, we detect the tumor earlier and they are a candidate for either breast conservation or mastectomy.
So, is the patient interested in breast conservation? Is the patient interested in mastectomy?
Neoadjuvant systemic therapy can take the form of chemotherapy (used for most estrogen receptor negative breast cancer or HER2 positive breast cancer) delivered for three to six months before surgery. For patients with estrogen-responsive breast cancer, we can treat with endocrine therapy, an oral medication they can take for four to six months prior to surgery. Both of these approaches can shrink the tumor prior to surgery and potentially make patients candidates for breast conservation. Also, oncoplastic surgery — removal of the tumor with advancement of the adjacent tissue to restore the shape of the breast — enables removal of larger tumors and still conserves the breast.
Breast conservation surgery is usually followed by radiation, whereas a mastectomy may not always be followed with radiation, depending on the size of the tumor and whether the lymph nodes are involved or not.
Ten years ago at my practice, we would meet with the patient, talk about surgery, operate on them, and send them to medical oncologists. Now, it’s meet with the patient, review the details of that breast cancer, and maybe recommend chemotherapy first. We look at the specifics of the tumor subtype — is it estrogen-responsive or progesterone-responsive? Does it over-express the HER2 protein? What is its grade? How aggressive is it?
For some of the more aggressive tumors, even if they’re small, such as triple negative or HER2-positive breast cancers, we would recommend treatment with chemotherapy first. This has been a real game-changer. Some patients still look at you and say, “Well, doctor, I just want you to cut my cancer out,” but that’s where the surgeon can sit down and talk to the patient and say, “If we treat you with the systemic therapy first, we have the potential of really actually completely eradicating the tumor. If we make it go away completely with the drug therapy, then that enables your surgery to be much smaller. You can then become a candidate for lumpectomy in the future.”
There are so many different options, and it’s really important for the patient to hear the pros and cons of each approach when they come in.
For patients who are eager for immediate surgical intervention, what are the benefits of taking time to undergo systemic therapy before surgery?
Patients want surgery tomorrow, and it’s really important for them to understand why you as a surgeon are recommending going with systemic therapy first. How does that influence their long-term outcome? How does that influence their surgical decisions? How does that then influence this therapy that we recommend after surgery?
If the chemotherapy eradicates the disease, they have a great outcome. If the chemotherapy shrinks the tumor, but there’s still some disease left, we may recommend additional chemotherapy that’s been shown to improve survival. Without that knowledge of the response, however, we can’t give them that additional therapy. It’s a complex network that weaves between the medical oncology recommendations, the surgical oncology recommendations, and the radiation recommendations, and the patient needs to hear all of that from the surgeon because we’re often the first person who meets with them.
