De-escalating and escalating surgery in the management of early breast cancer

In the setting of increased awareness regarding the need to address potential overtreatment in the management of breast cancer patients with favorable-prognosis disease, this article reviews three relevant instances in which the extent of surgery has been safely decreased: margin width in patients with ductal carcinoma in situ; axillary management in clinically node-negative women undergoing primary breast-conserving surgery; and the use of neoadjuvant chemotherapy followed by sentinel node biopsy for patients presenting with node-positive breast cancer. The management of the axillary nodes over the past decade highlights the potential to de-escalate surgery in the era of multimodality therapy. Similar opportunities exist for the use of radiotherapy. To fully realize the potential of de-escalating surgery, new communication strategies must be developed to convince patients that bigger is not necessarily better.