Avoid common mistakes on your manuscript.
Past
Since the 1970s, there has been a paradigm shift in the understanding of breast cancer from local tumor burden that requires aggressive local surgical therapy to a systemic disease from the outset. This paved the way toward de-escalation from mastectomy to breast-conservation surgery, and from axillary dissection to sentinel node biopsy over the last 5 decades. This was achieved primarily due to an earlier diagnosis resulting from better screening techniques. Additionally, targeted adjunctive therapies and genomic profiling of cancers that can accurately identify tumors that do not require toxic therapies has also de-escalated the use of systemic therapies. Approaches to improve surgical de-escalation continue to evolve, with less invasive strategies such as percutaneous tumor destruction with cryoablation.
Present
Breast cancer cryoablation has primarily concentrated on low-risk small tumors for both the elderly and poor surgical candidates. The American College of Surgeons Oncology Group (ACOSOG) 1072 study was the first large breast cancer cryoablation clinical study focused on unifocal invasive ductal carcinoma ≤2 cm, with subsequent surgical resection, that demonstrated successful tumor necrosis with hypothermia. Since then, cryoablation for low-risk estrogen receptor-positive/progesterone receptor-positive/human epidermal growth factor receptor 2-negative breast cancer ≤1.5 cm without resection has been shown to be safe and effective.1,2 Furthermore, we found cryoablation of the primary tumor and forgoing sentinel node biopsy offer an oncologically safe and feasible minimally invasive office-based procedure for patients with early-stage, low-risk breast cancer.3 Serendipitously, cryoablation, as opposed to resection, allows for retaining tumor-specific antigens in situ, promoting antitumor immune response. Cryoablation is also cost effective and is associated with excellent oncologic, physical, sexual, and cosmetic outcomes.4 Cryoablation therefore allows for ultimate de-escalation of surgery in select patients by decreasing treatment burden and improving patients’ quality of life.
Future
As more breast cancer patients become aware of cryoablation for low-risk subtypes, they are seeking out physicians who provide the service as an alternative to surgery, especially the elderly. However, at present no standard of care has been established for breast cancer cryoablation, with only one publication defining practical guidelines.5 The hypothesis that cryoablation leads to enhanced antitumor immune response needs to be thoroughly investigated, particularly for high-risk immunogenic breast cancers. As follow-up data accumulate, the safety and selection criteria for cryoablation will need to be defined for appropriate adoption of cryoablation. This will also entail a clearer definition of which patients can safely avoid sentinel node biopsy. These guidelines will need to consider optimism bias by patients and surgeons to ensure safety.6 In summary, cryoablation without surgical resection is a promising, less invasive approach for low-risk breast cancer, with an increased interest in leveraging the procedure for high-risk, hard-to-treat subtypes.
References
Habrawi Z, et al. Cryoablation: A promising non-operative therapy for low-risk breast cancer. Am J Surg. 2021;221:127–33. https://doi.org/10.1016/j.amjsurg.2020.07.028.
Fine RE, et al. Cryoablation without excision for low-risk early-stage breast cancer: 3-year interim analysis of ipsilateral breast tumor recurrence in the ICE3 Trial. Ann Surg Oncol. 2021;28:5525–34. https://doi.org/10.1245/s10434-021-10501-4.
Khan SY, et al. Cryoablation allows the ultimate de-escalation of surgical therapy in select breast cancer patients. Ann Surg Oncol. 2023. https://doi.org/10.1245/s10434-023-14332-3.
Khan SY, et al. The role of cryoablation in breast cancer beyond the oncologic control: COST and breast-Q patient-reported outcomes. Ann Surg Oncol. 2023;30:1029–37. https://doi.org/10.1245/s10434-022-12570-5.
Holmes D, Iyengar G. Breast cancer cryoablation in the multidisciplinary setting: Practical guidelines for patients and physicians. Life. 2023;13:1756. https://doi.org/10.3390/life13081756.
Miller ME, Siegler M, Angelos P. Ethical issues in surgical innovation. World J Surg. 2014;38(7):1638–43. https://doi.org/10.1007/s00268-014-2568-1.
Acknowledgment
The research reported in the original research article was funded through the ASCO Equipment Endowment for Excellence in Women’s Health.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosure
Michael W. Melkus, Sonia Y. Khan, Jaclyn Cole, and Rakhshanda Layeequr Rahman have no conflicts of interest to declare.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Melkus, M.W., Khan, S.Y., Cole, J. et al. ASO Author Reflections: Achieving Surgical De-Escalation of Breast Cancer Through Cryoablation. Ann Surg Oncol 31, 384–385 (2024). https://doi.org/10.1245/s10434-023-14335-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-023-14335-0