Real de-escalation or escalation in disguise?

Area of Science:

• Oncology
• Surgical Oncology
• Radiotherapy

Background:

• The past two decades show a trend towards de-escalating surgical therapy for early breast cancer (BC).
• Examples include reduced re-excision rates and replacing axillary lymph node dissection with sentinel lymph node biopsy (SLNB).
• Primary systemic treatment now utilizes less invasive staging like SLNB, targeted lymph node biopsy (TLNB), and targeted axillary dissection (TAD).

Purpose of the Study:

• To review the trend of surgical de-escalation in early breast cancer.
• To address concerns regarding potential escalation of other treatment modalities, such as radiotherapy.
• To highlight the need for an interdisciplinary approach integrating surgery and radiotherapy for optimal patient outcomes.

Main Methods:

• Review of numerous studies on surgical de-escalation in early breast cancer.
• Analysis of trends in surgical procedures and staging strategies.
• Examination of the interplay between surgical de-escalation and radiotherapy protocols.

Main Results:

• Reducing surgical extent in upfront surgery does not negatively impact locoregional recurrence or overall survival.
• Less invasive staging strategies are increasingly used in primary systemic treatment settings.
• Uncertainties in evidence may lead to radiotherapy escalation, and increasing mastectomies without genetic risk are noted.

Conclusions:

• Surgical de-escalation in early breast cancer is effective and does not compromise outcomes.
• Careful consideration of radiotherapy protocols is essential to avoid compensatory escalation.
• Future research should focus on interdisciplinary approaches for integrated de-escalation strategies, prioritizing quality of life and shared decision-making.