Surgical Oncology Clinics of North America

No abstract text is available yet for this article.

No abstract text is available yet for this article.

The COVID-19 pandemic was an unprecedented time that placed unique challenges on the screening and treatment of breast cancer in the United States. Collaboration among medical disciplines and societies provided guidelines and strategies to mitigate the exposure of patients and medical providers to the virus and provide optimal care. We discuss the changes that the pandemic had on the multidisciplinary management of breast cancer.

Breast cancer treatment, timeliness of care, and clinical outcomes are inferior for patients of Black race and Hispanic ethnicity, and the origin of these inequities is multifactorial. Owing to aggregate reporting of data in the United States for patients of Asian, Native Hawaiian, and Pacific Islander ancestry, disparities within and across these groups are difficult to appreciate. In large part due to low prevalence, male breast cancer remains understudied, and treatment algorithms are primarily extrapolated from research conducted in female patients...

Given the excellent prognosis and availability of evidence-based treatment, patients with early-stage breast cancer are at risk of overtreatment. In this review, we summarize key opportunities to incorporate value-based decisions to optimize the delivery of high-value treatment across the breast cancer care continuum.

Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.

Fertility and sexual health may be impaired by early breast cancer treatment in young women, and these issues should be addressed at diagnosis and through survivorship. Future fertility interest and risk should be considered and communicated, and early referral made to an infertility specialist for those interested. Data regarding safety of fertility preservation options as well as pregnancy after breast cancer are overall reassuring. Patients should be counseled about the impact of systemic therapies and breast surgeries on sexual health outcomes and educated about and referred as needed for available strategies for prevention and management of impairment...

The approval of preoperative immunotherapy combined with chemotherapy is a practice-changing advance for patients with early-stage triple-negative breast cancer. The optimal patient selection requires careful attention to staging and balancing potential risks with expected benefits, particularly as it relates to immune-related adverse events.

Although adjuvant breast radiotherapy has long been a universal component of breast conservation therapy (BCT), it is now clear that "breast cancer" is a broad class of many disparate diseases with varying natural histories and risk profiles. In turn, some breast conservation patients enjoy exceedingly favorable outcomes following surgery alone. Ongoing trials seek to identify such low-risk patient populations, hypothesizing that some may safely forego radiotherapy. Whereas prior-generation trials focused on clinicopathologic features for risk stratification, contemporary studies are employing molecular biomarkers to identify those patients who are unlikely to benefit significantly from radiotherapy...

In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients...

De-escalation of axillary management after neoadjuvant chemotherapy in clinically node-positive patients is feasible. The current literature shows this may be accomplished by sentinel lymph node biopsy (SLNB) with the use of dual tracer and removal of at least 2 sentinel lymph nodes, or by targeted axillary dissection (TAD). The accuracy of TAD has been consistently shown as better than that of SLNB. However, these techniques should only be offered to select patients without extensive axillary disease, understanding that long-term outcomes of minimal axillary surgery in this population are limited at this time...

This article reviews the incidence of nodal metastases in early-stage breast cancer and the need for axillary staging to maintain local control in the axilla or to determine the need for adjuvant systemic therapy across the spectrum of patients with breast cancer, and reviews clinical trials addressing this question. At present, sentinel lymph node biopsy should be omitted in women age ≥70 years with cT1-2 N0, HR+/HER2- cancers. The importance of nodal status in selecting patients for radiotherapy remains the main reason for axillary staging in younger postmenopausal women with cT1-2N0, HR+/HER2- cancers...

DCIS detection has increased dramatically since the introduction of screening mammography. Current guidance concordant care recommends surgical intervention for all patients with DCIS, followed by radiation and/or endocrine therapy for some. Adjuvant therapies after surgical excision have reduced recurrence rates but not breast cancer mortality. Given the lack of evidence of current treatment regimens and the morbidity associated with these treatments, there is concern that DCIS is over-treated. Active surveillance may be a favorable alternative for selected patients and is currently being investigated through four international clinical trials...

Multiple tools exist to assess a patient's breast cancer risk. The choice of risk model depends on the patient's risk factors and how the calculation will impact care. High-risk patients-those with a lifetime breast cancer risk of ≥20%-are, for instance, eligible for supplemental screening with breast magnetic resonance imaging. Those with an elevated short-term breast cancer risk (frequently defined as a 5-year risk ≥1.66%) should be offered endocrine prophylaxis. High-risk patients should also receive guidance on modification of lifestyle factors that affect breast cancer risk...

The primary prevention of breast cancer is a worthwhile goal for which the efficacy of antiestrogens is well established. However, implementation has been problematic related to low prioritization by providers and the reluctance of high-risk women to experience medication side effects. Emerging solutions include improved risk estimation through the use of polygenic risk scores and the application of radiomics to screening mammograms; and optimization of medication dose to limit toxicity. The identification of agents to prevent estrogen receptor negative or HER2-positive tumors is being pursued, but personalization of medical risk reduction requires the prediction of tumor subtypes...

No abstract text is available yet for this article.

No abstract text is available yet for this article.

Pre-clinical and clinical data clearly demonstrate the immune modulatory effects of radiotherapy (RT) but clinical trials testing RT + immunotherapy have been equivocal. An improved understanding of the immune modulatory effects of RT and how practical parameters of RT delivery (site and number of lesions, dose, fractionation, timing) influence these effects are needed to optimally combine RT with immunotherapy. Additionally, increased exploration of immunotherapy combinations with RT, beyond immune checkpoint inhibitors, are needed...

Image guidance for radiation therapy (RT) has evolved over the last few decades and now is routinely performed using cone-beam computerized tomography (CBCT). Conventional linear accelerators (LINACs) that use CBCT have limited soft tissue contrast, are not able to image the patient's internal anatomy during treatment delivery, and most are not capable of online adaptive replanning. RT delivery systems that use MRI have become available within the last several years and address many of the imaging limitations of conventional LINACs...

Proton therapy (PBRT) is a form of external beam radiotherapy with several dosimetric advantages compared with conventional photon (x-ray) radiotherapy. Unlike x-rays, protons deposit most of their dose over a finite range, with no exit dose, in a pattern known as the Bragg peak. Clinically, this can be exploited to optimize dose to tumors while delivering a lower integral dose to normal tissues. However, the optimal role of PBRT is not as well-defined as advanced x-ray-based techniques such as intensity-modulated radiotherapy...