Q-&-A Session With Duke's Chief of Breast Surgery

Breast cancer. Computer artwork of a malignant (cancerous) tumor (red) in a woman
Eun-Sil Shelley Hwang, MD, chief of breast surgery at Duke Health, is a leading expert on early-stage breast cancer. Earlier this year, she and her colleagues published a landmark study in the Journal of Clinical Oncology demonstrating that double mastectomy does not notably improve quality of life in patients with unilateral breast cancer. (Read more about the study in Issue 43.) In April 2016, she was named to TIME Magazine’s 2016 list of 100 most influential people.

Question: How did you become interested in early-stage breast cancer treatment?
Hwang: From the time I was a surgery resident, I found it fascinating that all stage 0 cancers were aggressively treated as though they were malignant, when, from a scientific point of view, it’s not clear they should all be treated as cancers. This inconsistency seemed like a potential opportunity for improvement.

Question: What have we learned about breast cancer treatment since you started in the field?
Hwang: We’re beginning to understand that for a lot of cancers, especially in the early stages, it’s more important that we focus on controlling the potential for spread rather than on the surgical removal of all the disease. The current approach has left millions of people cured of their cancer but with many troublesome adverse effects. In some patients, that tradeoff is completely justified, but, for others with slow-growing malignancies that may never have caused symptoms, the benefit is not so clear.

Clinical Trials at Duke
Check out Duke’s ongoing clinical trials for breast cancer. Hwang encourages referrals: “Patient participation in clinical trials is essential for improving treatment,” she says. “We’re destined to continue doing what we’re doing unless we get patients and their providers involved.”

Question: How can we better serve patients with early-stage cancers?
Hwang: As physicians, we need to do a better job of educating ourselves and our patients about the fact that everything we call cancer doesn’t have the same ability to kill, and so treating them all with the same aggressive stance doesn’t really make any sense. As we’re understanding how cancers differ by using advanced molecular testing, I think it’s necessary to try to understand the different malignant potentials and design our treatments to match the biologic significance of the tumors—or “make the punishment fit the crime,” as one of my professors used to say. It’s also important that we view our consultations with patients as educational opportunities to help them become active participants in their care.

Question: Where would you like to see the field to go?
Hwang: I think every medical condition needs to move toward a more personalized model of care because it’s no longer good enough to treat everyone the same. Breast cancer treatment has come a long way, and my hope is that we can repurpose the tools we’re developing in the breast cancer arena, like molecular risk stratification and statistical modeling, to identify which groups might benefit from a less-aggressive approach in all kinds of different diseases. The goal we share is to preserve the great outcomes we are getting for cancer treatment while reducing the lifelong adverse events and costs of treatment.