To the Editor Neoadjuvant chemotherapy (NACT) trials, such as NSABP B-18, confirmed that patients initially requiring mastectomy could be rendered eligible for breast-conserving surgery (BCS), increasing rates of conservation by about 8% in absolute terms.1 Nonetheless, there were slightly higher rates of ipsilateral breast tumor recurrence (IBTR) compared with patients suitable for BCS at presentation. This is likely associated with difficulties in determining pattern of disease response to NACT and poor radiopathological correlation despite improved imaging technology. These factors have limited potential reductions in the extent of surgery following NACT.2 Golshan et al3 provide data specifically on triple-negative breast cancers (TNBC) that have complete pathologic response rates of about 40%.3 Once again, conversion rates to BCS are increased approximately 8% from 76.5% to 83.8% (7.3%), and pathologic response rates are similar for patients irrespective of their candidacy for BCS at presentation. This secondary analysis of the BrighTNess trial examines conversion rates and not IBTR, without comment on margin reexcision or rates of completion mastectomy. However, it does provide interesting data on surgical choice and consequences of shared decision-making between patients and physicians. Among patients initially eligible for BCS, 70% underwent this surgical procedure, whereas only half of patients who become eligible for BCS after NACT chose this option (ie, 42 of 75 [56%]). Surgeon preference may have influenced this decision with uncertainty about patterns of tumor shrinkage and temptation to excise the original tumor footprint. Nonetheless, among US patients opting for mastectomy, more than two-thirds chose bilateral mastectomy, suggesting that patient choice was driving the surgical agenda. Interestingly, rates of contralateral surgery were much lower outside the United States and where managed health care systems are financially independent of insurance companies and subject to rationalization. Likewise, there was a 2.7-fold increased likelihood of BCS in Europe and Asia, and patients with BRCA gene mutations almost invariably chose bilateral mastectomy in the United States. Patients with TNBC (and especially a gene mutation) may have unfavorable perceptions about risks of ipsilateral and contralateral recurrence and choose more extensive surgery rather than BCS, whether unilateral or bilateral mastectomy. These aspects of surgical decision-making that appear to eschew BCS demand further investigation. There is emerging interest in omission of breast surgery in exceptional responders, with negative tumor bed biopsies and reliance on breast irradiation only.4 This may prove premature when rates of BCS remain stubbornly high in patients with TNBC with relatively high rates of pathologic response.
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Benson JR, Dumitru D. Extent of Breast Surgery After Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer. JAMA Surg. Published online May 13, 2020. doi:10.1001/jamasurg.2020.1001
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