Surgical Excision vs. Multiple Core Biopsies to Determine Pathological Response: Different Experts Differ

One of several “hot topic” sessions that took place at the recent Miami Breast Cancer Conference featured Patrick Borgen, MD, Chair, Department of Surgery at Maimonides Medical Center, going up against Dr. Pat Whitworth, Director of the Nashville Breast Center, Nashville, TN, in a friendly debate on the subject of surgical excision versus core biopsies to assess pathological response to treatment.

Dr. Borgen spoke in support of surgical excision, while Dr. Whitworth spoke in support of multiple core biopsies in place of surgery.

Dr. Borgen initiated the conversation by presenting the case of a 55-year-old patient who had completed neoadjuvant treatment for a 2.5 cm, ER-negative, HER2-positive breast cancer. She demonstrated a complete clinical response and asked about multiple image-guided vacuum-assisted biopsies (VAB) to assess for residual tumor burden.

Is VAB Ready for Prime Time?

Dr. Borgen offered healthcare providers in the audience four choices as to how to proceed with the patient:

  1. VAB is ready for prime time and if the core biopsies did not show residual cancer, I would refer her for radiotherapy
  2. VAB is not ready for prime time and I would encourage surgical excision
  3. I would encourage her to enter a trial, if available, that would offer VAB followed by surgical excision
  4. I would encourage her to enter a trial, if available, that would offer VAB alone in pCF patients

The fundamental question at hand was, are multiple image-guided core biopsies equivalent to surgical excision in determining pathologic complete response in breast cancer? The audience members appeared to have their doubts: Initially, 7% of respondents chose option 1, 40% chose option 2, 38% chose option 3, and the remaining 16% chose option 4.

Dr. Borgen stated that he intended to focus on two questions:

“Does the invasive procedure used to identify residual tumor burden after NST impact the eventual outcome in local/regional or systemic recurrence rates?” And, secondly, “Do multiple core biopsies, performed under local anesthesia, represent a true de-escalation in local disease assessment or control?”

In his next slide, Dr. Borgen noted that it is not safe to be wrong on the first question as “no imaging study is accurate in identifying pathological complete response (pCR).” He followed by sharing information from a San Antonio Breast Cancer Symposium, December 2021, presentation showing that “only one subgroup analysis out of six studies favored surgery avoidance.”

The Surgeon’s Conclusions

Dr. Borgen summarized his position in three final points:

  • Multiple VAB to quantify residual cancer burden after NST (No Special Type) is a reasonable modality to investigate and is consistent with the trend of de-escalation.
  • The available evidence from relatively small studies does not favor abandonment of surgery.
  • It is unclear whether this approach (VAB) represents a true de-escalation in invasive procedures.

The Future Belongs to VAB?

Dr. Whitworth took over from Dr. Borgen to argue on behalf of VAB, opening by stating that while the present practice is to use lumpectomy to detect pCR after neoadjuvant treatment for breast cancer, image-guided biopsy was the future. In support, Dr. Whitworth referenced research in which he participated that indicated approximately 50% of patients may not need surgery.

Posing the question, “Why consider selective elimination of breast cancer surgery?” Dr. Whitworth answered that there is no benefit for local control or survival in about 50% of surgical cases, while the downside of surgery includes risk of poor cosmetic outcome, infection, paresthesia, pain syndromes, lymphedema, and the need for reoperation. He further stated that Image-guided tissue sampling, such as vacuum-assisted core biopsy (VACB), can confirm pCR.

What About Patient Quality of Life?

Arguing that his position better favors a concern for patient quality of life, Dr. Whitworth noted that in one recent study, 100% of patients who opted against breast surgery strongly agreed or agreed that they would decide to forgo breast surgery again if given the chance in the future. Further, he noted that targeted imaging and biopsy can accurately identify patients without residual disease, and that studies are underway to ensure safety and efficacy in this approach.

Dr. Whitworth concluded his portion of the debate noting that there is an “obligation to study the possibility of no surgery,” particularly with value-based, patient-centered care in mind. He went on to say that eliminating surgery was a “natural extension of progress in breast cancer.”