Jana de Boniface

Jana de Boniface

Adjunct Professor
Visiting address: Nobels Väg 12A, 17165 Solna
Postal address: C8 Medicinsk epidemiologi och biostatistik, C8 MEB III de Boniface, 171 77 Stockholm
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About me

  • I am a general surgeon trained in Berlin and Västerås, today specialising in oncoplastic breast surgery. The seat of my clinical activities is Capio St Göran's Hospital, one of the three large Breast Centers in Stockholm. Born in Giessen, Germany, I moved to Humboldt University in Berlin after school and studied medicine as well as violin (Universität der Künste) until receiving my graduations in 1996 and 1999. I did my doctoral thesis on viral hepatitis C and psychological side effects of Ribavirin and interferon treatment and later continued with a PhD thesis on sentinel node biopsy in breast cancer at Uppsala University.

Research

  • My research, through a position as senior researcher at Karolinska Institutet, is focussed on two main clinical areas: axillary surgery and oncoplastic breast surgery. In addition, we have recently started a randomized trial within exercise oncology.

    Axillary surgery in breast cancer has undergone an enormous development since the 1990s. While we always performed an axillary clearance before that time, removing at least 10 lymph nodes from the armpit regardless of whether they were tumor-bearing or not, we today get more and more restrictive about the extent of axillary surgery. The reason for that if of course mainly the known risk of lymph edema, affecting about 20-25% of women after axillary clearance, and the fact that breast cancer is diagnosed earlier today, making is less likely that extensive axillary surgery contributes to any survival benefit at all.

    In the 1990s, the sentinel node biopsy was introduced, identifying the first lymph node/s draining the breast and representing the remaining axillary nodes. It is established today that no axillary clearance needs to be performed in case of a negative sentinel node. There are, however, additional data questioning the benefit of further axillary surgery even in the event of a tumor deposit (metastasis) in the sentinel node. We therefore started a large randomised trial, the SENOMAC Trial, analysing the effect of the omission of axillary clearance in this situation, the first results have been presented in San Antonio in December 2023 and the publication on recurrence-free survival is in press. 

    The next step of reducing axillary treatment is the randomized T-REX trial testing to reduce radiotherapy to the armpit, and the AXSANA study assessing how much axillary surgery we need to perform after preoperative chemotherapy.

    Oncoplastic surgery is the use of plastic surgical methods in order to make breast cancer surgery less mutilating, maintaining the same safety that conventional methods provide. While I actively promote the knowledge and use of oncoplastic techniques through training courses and certification processes, the issues of oncological safety and quality of life are the focus of my oncoplastic research. Thereby I try to support the safe use of volume displacement methods as well as reconstructive options, but I am also involved in analyses on the reasons for regional differences and the patient-reported outcomes after such surgery, especially in patients irradiated after implant-based reconstruction.

Teaching

  • Teaching oncoplastic breast surgery is a passion of mine as I believe that we can thereby provide tailored surgery to breast cancer patients. The complex assessment of tumor, stage, planned treatment, together with patient factors such as own desires and priorities, expectations, body shape and comorbidities are fascinating. To disseminate "oncoplastic thinking" and craftsmanship, I lead the annual national oncoplastic course in Sweden and have recently joined the Oncoplastic Breast Consortium.

Articles

All other publications

Grants

  • Swedish Cancer Society
    1 January 2023
    The sentinel node, or the gatekeeper, is the first lymph node in the armpit to receive lymph from the breast, and thus also the first place where tumor cells are found if spread via lymphatics occurs in breast cancer. If the sentinel node is healthy, it is not necessary today to remove several lymph nodes from the armpit (axillary evacuation). Since axillary dissection entails a considerable risk of problems with the arm, in recent years people have begun to refrain from axillary dissection even when there is limited tumor spread to the sentinel node. However, whether this is safe has not yet been proven. The current SENOMAC study tests whether axillary evacuation needs to be done in patients with breast cancer who have tumor spread to 1-2 gatekeeper glands. The study is randomized, which means that after their sentinel node biopsy, patients are randomized to either undergo axillary dissection or to refrain from it. The study has included 2768 patients from 5 European countries in 2015-2021. Via questionnaires, the participants tell us about their quality of life and arm function. The study wants to show that you can reduce surgery in the armpit and thus reduce the occurrence of problems with the arm without worsening the prognosis. Inclusion in the study is now closed and follow-up is ongoing. With the SENOMAC study, I want to show that axillary evacuation does not need to be done in case of limited tumor spread of breast cancer to the sentinel node. Indirectly, this means that it is not the surgery itself, but rather other additional treatments, which protect against recurrence. I want to bring about a change in guidelines where surgery in the armpit is only as extensive as needed but not unnecessarily large. This needs to apply to all groups of patients, not just the sample of individuals who have participated in previous studies. With this, I want to achieve that the quality of life and arm function is improved for a large number of women.
  • Swedish Research Council
    1 January 2022 - 31 December 2025
    The role of completion axillary lymph node dissection (ALND) in sentinel node (SN)-positive breast cancer is questioned since key randomized trials showed no survival differences comparing completion ALND and SN biopsy alone. These trials however were significantly underpowered, and in addition, patients undergoing mastectomy or those with larger tumors were not included. Thus, there is a need for additional prospective data validating previous results with sufficient statistical power to detect even smaller survival differences, and including the crucial subgroup of mastectomy patients. The SENOMAC trial was initiated in 2015 as an international randomized phase 3 clinical trial including patients with clinically node-negative T1-T3 breast cancer and up to two SN macrometastases. Patients are randomized 1:1 to undergo completion ALND or not, and both breast-conserving surgery and mastectomy are eligible interventions. The non-inferiority endpoint is overall survival at 5 years with a non-inferiority margin of 2.5% (94% versus 91.5%), targeting an overall accrual of 3000 patients. Secondary endpoints such as arm morbidity and health-related quality of life are measured by patient-reported outcomes (PROs) at 1, 3 and 5 years. The SENOMAC Trial has to date including 2395 patients, 34% of whom operated by mastectomy, from 5 European countries. Enrolment will be closed at the end of 2021, and the first report on the primary endpoint is expected in 2024.
  • Swedish Research Council
    1 December 2021 - 30 November 2025
  • Swedish Cancer Society
    1 January 2020
    The sentinel node, or gatekeeper, is the first lymph node in the armpit to receive lymph from the breast, and thus also the first place where tumor cells gather if spread with the lymph flow occurs in breast cancer. If the sentinel node is healthy, it is not necessary today to remove several lymph nodes from the armpit (axillary evacuation). Since axillary evacuation entails a considerable risk of subsequent problems with the arm, it has in recent years begun to investigate whether it is possible to refrain from axillary evacuation even when there is microscopic tumor spread to the sentinel node. So far, the results are promising, but the data is still too small to be implemented on a broad front. The current study, dubbed SENOMAC, raises the question of whether axillary evacuation needs to be performed in patients with breast cancer who have microscopic tumor spread to the concierge. In order to obtain a scientifically high-quality answer, the study is carried out with randomization, which means that patients after their sentinel node biopsy are randomized to either undergo axillary evacuation or also refrain from it. The study is ongoing at many hospitals in 6 different European countries. The aim is to show that it is possible to limit the scope of surgery in the armpit, and thereby reduce the incidence of problems with the arm, without worsening the prognosis. With the SENOMAC study, I want to show that axillary evacuation does not need to be done by microscopic tumor spread of breast cancer to the gatekeeper (sentinel node). Indirectly, this means that it is not the surgery itself, but rather other additional treatments, that protect against relapse. I want to bring about a change in national and international guidelines where surgery in the armpit is only as extensive as needed but not unnecessarily large. This needs to apply to all groups of patients, not just the sample of individuals who have participated in previous studies. With this, I want the quality of life and arm function to be improved for a large number of women.
  • Swiss National Science Foundation
    1 August 2019 - 31 July 2026
    According to the Swiss Certified Breast Center Database, 1580 implant-based breast reconstructions (IBBR) were performed at Swiss certified breast cancer centers in 2017. The optimal positioning of the breast implant above (pre-pectoral) or below the pectoralis major muscle (sub-pectoral) is currently not clear when performing IBBR after nipple- or skin-sparing mastectomy (NSM, SSM) for breast cancer treatment or prevention. Pre-pectoral positioning respects the anatomic position of the mammary gland and avoids surgery-induced alterations of the pectoralis major muscle. Therefore, it offers a variety of potential advantages including improved physical well-being, easier recovery, and no animation deformity caused by muscle movement. However, the lack of muscle coverage may create its own set of problems, including a higher risk of complications like capsular contracture and rippling of the implant.Sub-pectoral IBBR is still standard care in many countries, but pre-pectoral IBBR is increasingly performed. However, despite this change in practice, there is no clear evidence to support the assumption that pre-pectoral positioning offers relevant improvements in patient-relevant outcomes after surgery in the long term. We hypothesize that pre-pectoral IBBR is associated with improved quality of life compared to sub-pectoral IBBR by improving long-term physical well-being of the chest. We propose a multicenter, randomized superiority trial with 24 months follow-up to test this hypothesis. We designed the trial to be fit for that purpose by applying the PRECIS-2 requirements for pragmatism. The trial will include 372 patients undergoing NSM or SSM and IBBR for prevention or treatment of breast cancer at least 13 Swiss and six non-Swiss OPBC study sites. Randomization will be stratified by center and uni- versus bilateral surgery. Patients will be randomized 1:1 to the experimental group with pre-pectoral IBBR and the control group with sub-pectoral IBBR. Patient advocates have helped develop the protocol and select the primary endpoint, which will be patient-reported long-term physical well-being of the chest measured by the BREAST-Q scale “physical well-being: chest” 24 months after NSM or SSM and IBBR. Secondary endpoints will include safety, overall quality of life, patient satisfaction, objective aesthetic outcomes and burden on patients. We believe that this trial is original, relevant as it addresses a specific clinical research field that is important and under-investigated, and is feasible for the following reasons: First, the corresponding applicant is an oncoplastic surgeon with experience in performing multicenter randomized trials. Second, he developed this proposal with the help of his co-applicant, a reconstructive breast surgeon specialized in breast reconstruction, and a team of patient advocates and experienced clinical research partners from all relevant disciplines. Third, a strong network of recruiting centers from public and private settings that has proved to operate well together in the past will ensure sufficient patient accrual.
  • Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection – the randomized controlled SENOMAC trial.
    Swedish Cancer Society
    1 January 2019
    The sentinel node, or gatekeeper, is the first lymph node in the armpit to receive lymph from the breast, and thus also the first place where tumor cells gather if spread with the lymph flow occurs in breast cancer. If the sentinel node is healthy, it is not necessary today to remove several lymph nodes from the armpit (axillary evacuation). Since axillary evacuation entails a considerable risk of subsequent problems with the arm, it has in recent years begun to investigate whether it is possible to refrain from axillary evacuation even when there is microscopic tumor spread to the sentinel node. So far, the results are promising, but the data is still too small to be implemented on a broad front. The current study, dubbed SENOMAC, raises the question of whether axillary evacuation needs to be performed in patients with breast cancer who have microscopic tumor spread to the concierge. In order to obtain a scientifically high-quality answer, the study is carried out with randomization, which means that patients after their sentinel node biopsy are randomized to either undergo axillary evacuation or also refrain from it. The study is ongoing at many hospitals in 6 different European countries. The aim is to show that it is possible to limit the scope of surgery in the armpit, and thereby reduce the incidence of problems with the arm, without worsening the prognosis. With the SENOMAC study, I want to show that axillary evacuation does not need to be done by microscopic tumor spread of breast cancer to the gatekeeper (sentinel node). Indirectly, this means that it is not the surgery itself, but rather other additional treatments, that protect against relapse. I want to bring about a change in national and international guidelines where surgery in the armpit is only as extensive as needed but not unnecessarily large. This needs to apply to all groups of patients, not just the sample of individuals who have participated in previous studies. With this, I want the quality of life and arm function to be improved for a large number of women.
  • Do you need to evacuate several lymph nodes from the armpit at early breast cancer with microscopic spread to sentinel node (the porter gland)?
    Swedish Cancer Society
    1 January 2017
    Sentinel node, or the concierge, is the first lymph node in the armpit that receives lymph from the breast, and thus also the first site where tumor cells accumulate if proliferation with the lymph flow occurs in breast cancer. If sentinel node is healthy, one does not need to remove several lymph nodes from the armpit (axillary space). Since axillary spasm causes a considerable risk of subsequent arthroplasty, the last few years have begun to investigate whether axillary space can be dispensed with even when there is microscopic tumor spread to the sentinel node. So far, the results are promising, but the data is still too small to be implemented on a broad front. The current study, which has been named SENOMAC, raises the question of the need for axillary evacuation in patients with breast cancer who have microscopic tumor spread to the concierge. In order to obtain a scientifically high-quality response, the study is carried out with randomization, which means that patients after their sentinel node biopsy are randomized to either undergo axillary clearance or also abstain from it. The study is ongoing at many hospitals both in Sweden and in Denmark. The goal is to show that one can limit the extent of the surgery in the armpit, and thus reduce the incidence of the arm, without impairing the prognosis. With the SENOMAC study, we want to show that axillary clearance does not need to be done in microscopic tumor proliferation of the breast cancer to the sentinel node. Indirectly, this means that it is not the surgery itself, but rather the usual additional treatments that protect against relapse. We want to make sure that surgery in the armpit is just as extensive as is needed but not unnecessarily large, and that the quality of life and the arm function are thereby improved for a large number of women every year.
  • Do you need to evacuate several lymph nodes from the armpit at early breast cancer with microscopic spread to sentinel node (the porter gland)?
    Swedish Cancer Society
    1 January 2016
    Sentinel node, or the concierge, is the first lymph node in the armpit that receives lymph from the breast, and thus also the first site where tumor cells accumulate if proliferation with the lymph flow occurs in breast cancer. If sentinel node is healthy, one does not need to remove several lymph nodes from the armpit (axillary space). Since axillary spasm causes a considerable risk of subsequent arthroplasty, the last few years have begun to investigate whether axillary space can be dispensed with even when there is microscopic tumor spread to the sentinel node. So far, the results are promising, but the data is still too small to be implemented on a broad front. The current study, which has been named SENOMAC, raises the question of the need for axillary evacuation in patients with breast cancer who have microscopic tumor spread to the concierge. In order to obtain a scientifically high-quality response, the study is carried out with randomization, which means that patients after their sentinel node biopsy are randomized to either undergo axillary clearance or also abstain from it. The study is ongoing at many hospitals both in Sweden and in Denmark. The goal is to show that one can limit the extent of the surgery in the armpit, and thus reduce the incidence of the arm, without impairing the prognosis. With the SENOMAC study, we want to show that axillary clearance does not need to be done in microscopic tumor proliferation of the breast cancer to the sentinel node. Indirectly, this means that it is not the surgery itself, but rather the usual additional treatments that protect against relapse. We want to make sure that surgery in the armpit is just as extensive as is needed but not unnecessarily large, and that the quality of life and the arm function are thereby improved for a large number of women every year.
  • Do you need to evacuate several lymph nodes from the armpit at early breast cancer with microscopic spread to sentinel node (the porter gland)?
    Swedish Cancer Society
    1 January 2015
    Sentinel node, or the concierge, is the first lymph node in the armpit that receives lymph from the breast, and thus also the first site where tumor cells accumulate if proliferation with the lymph flow occurs in breast cancer. If sentinel node is healthy, one does not need to remove several lymph nodes from the armpit (axillary space). Since axillary spasm causes a considerable risk of subsequent arthroplasty, the last few years have begun to investigate whether axillary space can be dispensed with even when there is microscopic tumor spread to the sentinel node. So far, the results are promising, but the data is still too small to be implemented on a broad front. The current study, which has been named SENOMAC, raises the question of the need for axillary evacuation in patients with breast cancer who have microscopic tumor spread to the concierge. In order to obtain a scientifically high-quality response, the study is carried out with randomization, which means that patients after their sentinel node biopsy are randomized to either undergo axillary clearance or also abstain from it. The study is ongoing at many hospitals both in Sweden and in Denmark. The goal is to show that one can limit the extent of the surgery in the armpit, and thus reduce the incidence of the arm, without impairing the prognosis. With the SENOMAC study, we want to show that axillary clearance does not need to be done in microscopic tumor proliferation of the breast cancer to the sentinel node. Indirectly, this means that it is not the surgery itself, but rather the usual additional treatments that protect against relapse. We want to make sure that surgery in the armpit is just as extensive as is needed but not unnecessarily large, and that the quality of life and the arm function are thereby improved for a large number of women every year.
  • Swedish Research Council
    1 January 2015 - 31 December 2017

Employments

  • Adjunct Professor, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 2024-2028

Degrees and Education

  • Docent, Karolinska Institutet, 2014

Distinction and awards

  • Jeanne Petrek Memorial Lecturer 2025, Memorial Sloan Kettering Cancer Center, 2025
  • Annual Award, Swedish Breast Cancer Association, 2024
  • Jubilee Award 2024, Swedish Medical Association, 2024

Supervision

  • Supervision to doctoral degree

    • Nida Khan, Breast reconstruction: a critical analysis of modern strategies, their associated economic burden and patient-reported outcomes, 2024-
    • Yihang Liu
    • Matilda Appelgren
    • Lea Stark
    • Martina Rossland
    • Christine Obondo

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