Prof. Dr. Arda Işık: In Breast Cancer, There Is No Room for the Thought “It’s Too Late”

In breast cancer, early diagnosis matters greatly because it means catching the disease at an earlier stage and widening the treatment options. Yet today, treatment is not shaped by stage alone. The tumor’s biological characteristics, hormone receptors, HER2 status, lymph node involvement and, if present, distant spread are evaluated together to build a patient-specific treatment plan.

In recent years, new approaches such as targeted therapies, immunotherapy and antibody-drug conjugates have considerably widened the options, particularly for breast cancers with certain biological features. The use of systemic treatment before surgery in locally advanced disease has also changed the timing and extent of surgery.

That is why a patient diagnosed with breast cancer should not lose hope by thinking “It’s too late.” Even when the disease is advanced, treatment options continue to be assessed according to its biology, its spread and the response to therapy. It is known that even in metastatic disease, different systemic treatments can keep the disease under control, and some patients continue their lives on treatment for many years.

We spoke about this changing approach with Prof. Dr. Arda Işık, a surgeon known for his expertise in breast surgery. Working as Professor of General Surgery at Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Prof. Işık is a surgeon specialized in breast surgery. Having successfully completed the European Breast Surgery Qualification exam, EBSQ in Breast Surgery, and earned the title FEBS in Breast Surgery, he is an academic who trained abroad in advanced breast disease and has authored scientific work in the field.

We asked Prof. Işık the questions patients wonder about most: from what a newly diagnosed patient should know first to treatment options in advanced disease, from breast-conserving surgery to the timing of surgery in locally advanced tumors, from changes in axillary surgery to new-generation therapies, and what patients should look for when choosing a breast surgeon.

Professor, a patient who has just been diagnosed with breast cancer usually thinks, “How advanced is it?” and “What happens next?” How do you actually look at the disease when deciding on treatment?

We do not decide on treatment by looking only at the size of the tumor or the stage of the disease. First, we assess the spread within the breast, the condition of the lymph nodes in the armpit and whether there is spread to distant organs. Beyond that, the biological characteristics of the tumor are very important to us.

Estrogen and progesterone receptors, HER2 status, the histological features of the tumor and, in the patients who need it, genetic features can change the treatment approach. If two patients at the same stage have tumors with different biology, the treatment may be different too.

For this reason we no longer treat breast cancer as a single disease. First we define the disease correctly, then we determine the most suitable treatment sequence for that patient. Surgery is an important part of that plan, but it does not have to be the first step in every patient.

When breast cancer is diagnosed at an advanced stage, patients often think, “Is it too late?” What are the treatment options today for a patient diagnosed at an advanced stage?

This is a very important point. Early diagnosis is of course extremely valuable, because the earlier the disease is caught, the greater our options and chances of success. But being diagnosed at an advanced stage does not mean there are no treatment options left.

In locally advanced breast cancer in particular, it can be possible to shrink the tumor with systemic treatment first and then reassess surgery. Even if the disease has spread to distant organs, treatment does not end. The aim of treatment then varies with the biology of the disease, but most of the time it is to keep the disease under control, extend life and preserve quality of life.

Today, metastatic breast cancer has several options: hormone therapies, targeted therapies, chemotherapy, immunotherapy and treatments selected according to biomarkers. Some patients can receive treatment for many years with their disease under control.

So telling a patient “You are too late, there is nothing to be done” does not match the reality of breast cancer treatment today. An advanced disease shows that treatment may be more complex; not that treatment is over.

“An advanced disease shows that treatment may be more complex; not that treatment is over.”

One of patients’ greatest fears is “Will I lose my breast?” In which patients is breast-conserving surgery possible today?

We hear this fear very often. But today, breast-conserving surgery is an important treatment option in suitable patients.

Here we do not look only at how many centimeters the tumor is. We evaluate together its location in the breast, the ratio between the breast and the tumor, whether the disease is in a single area or several, and whether safe surgical margins can be achieved when the tumor is removed.

In some patients, systemic treatment given before surgery can also shrink the tumor markedly. This allows surgical options to be reassessed in some patients who initially did not seem suitable for breast-conserving surgery.

Our aim is not to preserve the breast in every patient at all costs. The real goal is not to remove more tissue than necessary in a suitable patient, without compromising oncological safety.

Patients sometimes ask, “If I’m going to have surgery anyway, why am I receiving chemotherapy or another drug treatment first?” What is the surgical advantage of treatment before surgery?

This is a question patients ask very often, and it is important for understanding the treatment process. In some breast cancer patients, instead of operating first, we prefer to give systemic treatment suited to the tumor’s biology before surgery.

There are several reasons. First, we get the chance to see how the tumor responds to treatment. The tumor can shrink, and in some patients who were initially not suitable for breast-conserving surgery, that shrinkage allows a breast-conserving operation to be reconsidered.

Treatment before surgery has particular importance in HER2-positive and triple-negative breast cancers. Here we use the tumor’s response not only to shrink it but also to plan subsequent treatment. Whether disease remains after surgery gives us important information on whether additional treatments are needed in some patients.

So we should not think of treatment before surgery as “delaying the operation.” On the contrary, in the right patient it lets us plan surgery better, avoid a wider operation than necessary, and shape the patient’s later treatment according to the tumor’s real response.

Of course, not every patient receives treatment before surgery. The decision is made in a multidisciplinary way, evaluating the tumor’s biology, its size, the state of the lymph nodes, the spread of the disease and the patient’s general characteristics together.

Why do we care so much about the response to treatment before surgery? What does the pathology result after surgery tell a surgeon?

In patients who receive treatment before surgery, the aim of the operation is not only to remove the tumor but also to reveal the response to treatment. When we examine the removed breast and lymph nodes under pathology after surgery, we can see how much living cancer tissue remains in the tumor. In some patients we see that the invasive cancer cells have disappeared completely. We call this a pathological complete response.

In HER2-positive and triple-negative breast cancers in particular, the response to pre-surgical treatment can provide important information for planning the next treatment. Conversely, finding residual disease after surgery matters for the patient’s risk assessment and may bring additional treatments onto the agenda in some patients. So we should not see treatment before surgery merely as “shrinking the tumor.” The tumor’s biological response helps shape the treatment that follows.

Why has the idea that “more surgery is better treatment” changed in breast cancer?

Because we now determine the extent of surgery according to the biology and spread of the disease. In the past, wider surgery was thought to be always safer. Yet the scientific data accumulated over time have shown that, when the right patient is selected, more limited surgery can also be oncologically safe.

Breast-conserving surgery is one of the most important examples. We see a similar change in the armpit. By avoiding unnecessary lymph node dissections, we try to reduce the risk of complications such as lymphedema and restricted shoulder movement. I do not approach breast surgery as “the more tissue I remove, the better.” What matters is to treat the disease with adequate oncological safety while avoiding unnecessary surgery.

“What matters is to treat the disease with adequate oncological safety while avoiding unnecessary surgery.”

For this reason, more limited surgery can also be done on the lymph nodes in the armpit. In which patients can extensive dissection be avoided?

In axillary surgery, the decision is made by evaluating the patient’s clinical findings, imaging results, the tumor’s features and the treatments received together. In early-stage, suitable patients, sentinel lymph node biopsy is often enough to evaluate the armpit. In some selected patients, even when limited lymph node involvement is found, going straight to a full axillary dissection may not be necessary. The aim is not to skip evaluating the armpit; it is to obtain the necessary information without placing more surgical burden on the patient than needed. Axillary dissection can have long-term consequences such as lymphedema, restricted shoulder movement and sensory changes. So instead of performing the same armpit operation on every patient, we need to decide according to the patient’s real needs.

We hear terms like “HER2-low” more often in recent years. Do these new definitions, unfamiliar to patients before, really change treatment?

Yes, there have been important developments in this area, particularly in advanced breast cancer.

We used to think of HER2 assessment mostly as positive or negative. But some tumors classified as HER2-negative can also have a low level of HER2 expression. For a portion of these patients, new-generation treatments called antibody-drug conjugates have come onto the agenda. The important development here is this: the more precisely we define the biological features on the surface of the tumor, the more we see that patients we previously assessed in the same group can actually differ from one another.

However, patients should not think, “My result is HER2-low, so this particular drug will certainly be used.” The treatment decision is made by evaluating together the tumor’s stage, hormone receptors, previous treatments and the patient’s general condition.

Treatment options have also grown in triple-negative breast cancer. What has changed for these patients today?

Triple-negative breast cancer used to be one of the groups with more limited treatment options. In recent years, though, there have been important developments. One is adding immunotherapy to chemotherapy before surgery in early-stage, suitable high-risk patients and continuing treatment after surgery. We can also benefit from targeted therapies in certain patients with a BRCA1 or BRCA2 mutation.

Another important development is research into new treatments for patients with residual disease in the tumor tissue after surgery. For example, in NCI-supported studies, new drug combinations are being investigated in triple-negative breast cancer with residual disease after surgery, along with whether circulating tumor DNA in the blood can be used in treatment decisions. These are not yet standard practice for every patient, but they matter for approaches that could personalize treatment in the future.

From a breast surgeon’s point of view, what should patients pay most attention to today when choosing a surgeon?

Breast surgery is a field within general surgery that requires special experience and constantly updated knowledge. So patients should not settle for simply looking for “a good surgeon”; it is important to choose a physician with special training and experience in breast surgery.

The surgeon’s experience in breast cancer surgery, command of breast-conserving surgery and oncoplastic approaches, experience in axillary surgery and keeping up with current treatment approaches are important criteria.

I think international qualifications are valuable in this respect. Qualifications specific to breast surgery, such as EBSQ in Breast Surgery, are an important indicator for assessing a surgeon’s knowledge and skill in this field.

But a title alone is not enough. It is also important that the patient can understand why the proposed operation is recommended, can ask about alternatives, and knows that the surgeon works within a multidisciplinary team.

Is reaching the right center as important as choosing the right surgeon?

Absolutely. Breast cancer treatment is not just the operation the surgeon performs. From the diagnostic stage on, the patient needs to be evaluated within a system in which radiology, pathology, general surgery, medical oncology and, when necessary, radiation oncology work together.

One of the important advantages of Göztepe Prof. Dr. Süleyman Yalçın City Hospital is that the patient can reach different specialties within the same health system. This matters especially in breast cancer, where diagnostic and treatment decisions are linked.

What matters to me is that the process does not break while the patient is referred from one branch to another. Breast cancer treatment is not a “surgery appointment”; it is a process that starts at diagnosis and continues with treatment, pathology assessment and subsequent therapies.

“Breast cancer treatment is not a ‘surgery appointment’; it is a process that starts at diagnosis and continues with treatment, pathology assessment and subsequent therapies.”

During treatment, patients often struggle not only with the disease but also with fear. How do you assess the place of doctor-patient communication in treatment?

It is only natural for a patient diagnosed with breast cancer to be afraid. Suddenly they begin thinking about the disease, the surgery, chemotherapy, the appearance of the breast and their future. So it is not enough to tell the patient “We will do this operation.” We need to explain why we recommend that operation, whether there are other options and what the next stages of treatment are.

In surgery especially, it is important to give the patient the chance to ask questions. “Can we save my breast?”, “How many lymph nodes will be taken from my armpit?”, “What will happen after surgery?” are all things the patient needs to know. I care a great deal that the patient understands the treatment process, because when patients know what they will face, they can take part in decision-making more consciously.

What would you like to say to patients, finally, during Breast Cancer Awareness Week?

New developments and new treatment options emerge in breast cancer treatment every day. I recommend that our patients trust their doctors, carry out their treatment together with their physicians and not lose hope. Because for patients diagnosed with breast cancer today, we have far more treatment options than in the past, and these developments continue.

Interview: Melis Bayraktar

This interview is for informational purposes; consult your physician for diagnosis and treatment decisions.