Breast Cancer: Less is More Says Surgical Chief

When it comes to breast cancer surgery, sometimes “less is more,” Memorial Sloan Kettering (MSK) Breast Surgical Service Chief Dr. Monica Morrow says.

As simple as it sounds, it proves be quite difficult for health care providers, as well as patients, to accept that evidence-based medicine recommends less surgery, not more, for women with breast cancer, Dr. Morrow said in a video for Breast Cancer Awareness Month released by MSK via Twitter.
Memorial Sloan Kettering Cancer Center has “the largest experience in the world with [an] approach in over 700 women,” she said. “We have now shown that if a woman is having a lumpectomy and radiation and has cancer in only one or two sentinel nodes, we don’t need to take out the rest of the lymph nodes.”

“We have found that we’ve saved 84% of them from having their lymph nodes removed, which is something that has really eased the burden of their treatment.” This kind of clinical innovation, however, is not readily adopted in practice. Why not?

“The idea that less is more is one that has been very difficult for both physicians and patients to accept, because somehow it seems like if you have something bad like cancer, a bigger operation must be a better operation that cures more cancer,” she said. However, “clinical trials over the years have shown us that that is really not the case.”

This is partly because of “multidisciplinary treatment, meaning we now treat breast cancer not just with surgery the way we did a hundred years ago, but with surgery, and radiation, and drug therapy.”

“So the benefits of the radiation and the drug therapy allow us to do a smaller surgery, like a lumpectomy, and still get the same survival as a mastectomy,” she noted.

This raises an obvious question: if breast cancer treatment relies more on drug therapy than surgery, how should we value the drug used for that treatment? Most of us are not surprised to hear surgery costs $100,000 or $200,000, or more. But what of a cancer treatment in the form of a drug administered by a physician? How much should that treatment cost? How much of that treatment should be covered by insurance?

The move toward a “less is more” approach to breast cancer surgery may also have positive implications for drug costs for breast cancer patients in that the value of those medications will be more apparent.

When real-world evidence tells a story, will we listen? Informing patients, providers, and insurers as to the best use of their health care dollars, for example, ensuring drug therapy is covered as robustly as surgery, would be a good start.