Breast-Conserving Surgery in BRCA Mutation Carriers: A Paradigm Shift Toward Individualized, Multidisciplinary Care

Breast cancer associated with BRCA1 and BRCA2 mutations presents unique therapeutic challenges, traditionally favoring mastectomy due to concerns over recurrence and new primaries. However, evolving evidence and advances in multimodal therapy have reshaped this paradigm, positioning breast-conserving surgery (BCS) as a viable option for selected carriers. This narrative review synthesizes current data from meta-analyses, retrospective cohorts, and pivotal studies, including a multicenter analysis which affirmed oncologic equivalence between BCS and mastectomy when combined with radiotherapy and systemic therapy. While meta-analyses confirm higher local events following BCS, survival remains comparable, indicating that recurrence reflects genetic predisposition rather than surgical inadequacy. Optimized systemic treatments, including chemotherapy, endocrine therapy, risk-reducing salpingo-oophorectomy, and PARP inhibitors, further mitigate recurrence risk. Meanwhile, patient-centered outcomes favor BCS: studies consistently link it to improved body image, psychosocial well-being, and quality of life, especially for younger BRCA carriers. Fertility-preserving options remain viable, with evidence supporting the safety of pregnancy, breastfeeding, and assisted reproductive technologies in BRCA-mutated survivors. These findings support individualized surgical planning for BRCA carriers within multidisciplinary care, balancing oncologic safety, systemic strategies, and psychosocial priorities. BCS should be considered a standard option for well-selected patients in hereditary breast cancer management.