Local therapy for breast cancer in the molecular era: relevant or relic?

Local therapy (surgery and radiation) is an essential component of breast cancer treatment. Yet, based on clinical trial results dating from the 1980s, the magnitude of local therapy interventions has been decreasing. Now, with the emergence of tailored systemic therapies, their increasing use in the neoadjuvant setting, and their high rates of pathologic complete response (pCR), the relevance of local therapy is being questioned. However, given our present inability to assess pathologic response without surgery, the low pCR rates in common subtypes of breast cancer, and the survival advantages with nodal radiation, local therapy remains not only relevant but crucial to a comprehensive breast cancer treatment plan. In the future, as gene profiling of individual patient tumors progresses and allows for precise tailoring of therapy, it is conceivable that surgery and/or radiation would not be required in some patients. However, the notion that brief, low-morbidity local therapy options, which synergize with prolonged and potentially morbid systemic regimens, would not be relevant for most patients is beyond the horizon at the moment.