Breast cancer research continues to expand rapidly. We recently spoke with Roshni Rao, MD, Chief of Breast Surgery, about the latest developments in the groundbreaking I-SPY trial.
I-SPY (Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging and Molecular Analysis) is a collaborative multi-institutional study that aims to personalize treatments for high-risk breast cancer by using an adaptive model that evaluates the effectiveness of neoadjuvant therapies—medications given before surgery.
Last year, Dr. Rao shared key insights on how the I-SPY trial has already changed the treatment landscape by demonstrating no difference in recurrence rates between mastectomy and lumpectomy for certain patients who respond well to pre-surgery therapies, a surprising revelation that challenges long-standing assumptions.
In this follow-up interview, Dr. Rao delves a little deeper into the most recent findings, including minimizing lymph node removal, the evolving role of radiation, and how these advancements are shaping the future of breast cancer treatment.
Are there any new insights from the I-SPY trial that we should know?
One of the recent studies from the I-SPY trial focused on removing the clipped node during surgery. What's important about this is the idea of de-escalating axillary surgery—basically, removing the fewest number of lymph nodes that we absolutely have to. Especially in breast cancer patients, we're removing fewer and fewer lymph nodes. One of the ways we do this is by placing a clip in the lymph node before surgery, so when we operate, we can find and remove that specific node. This approach allows us to minimize lymph node removal while still being effective.
Why is minimizing lymph node removal so important in breast cancer surgery?
The fewer lymph nodes we remove, the lower the risk of complications like lymphedema, nerve issues, and swelling of the arm. These complications can significantly impact a patient’s quality of life. The exciting part of the I-SPY trial is that it's helping us target only the lymph nodes that need to be removed, avoiding unnecessary surgery while still treating the cancer effectively. It’s a huge step forward in reducing the collateral damage of surgery.
How does the clipped lymph node help during the surgery itself?
When breast cancer spreads, it often goes to the lymph nodes under the arm first. We biopsy those nodes at diagnosis, and if cancer is found, we typically treat the patient with neoadjuvant therapy—chemotherapy, immunotherapy, or another treatment—to try to clear the cancer from those nodes. That's why we place a clip in the lymph node before treatment, so during surgery, we know exactly which node to remove. The study showed that more and more surgeons in the I-SPY trial are finding and removing the clipped node and avoiding the removal of unnecessary lymph nodes, which is key.
How has the I-SPY trial changed the approach to treating lymph nodes?
The I-SPY trial has really shown us that we can safely reduce the extent of surgery by clipping and removing just the affected lymph nodes. This reduces the need for extensive lymph node removal, which helps us avoid complications like lymphedema and nerve damage. We’re also working on down-staging the axilla by treating the cancer in the lymph nodes before surgery, so we can remove even fewer nodes. This personalized approach is a huge step forward.
What are the next steps for the I-SPY trial?
I-SPY is doing a lot of work now on the role of radiation. Traditionally, if someone had cancer in their lymph nodes, they would always get radiation afterward. But now we’re seeing that if the patient responds well to treatment and there’s no cancer left in the lymph nodes at the time of surgery, they may not need radiation. That’s the next step—figuring out where we can safely de-escalate radiation. We’re also collecting more data on this as part of the I-SPY trial, to refine how we use radiation in breast cancer treatment.
Related:
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- State of the Union: Breast Care
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