De-escalating breast and axillary surgery in breast cancer: evidence, controversies, and future directions

The surgical management of breast cancer has achieved considerable improvement, shifting from radical resections toward increasingly conservative approaches driven by the advances in systemic therapy, precision imaging, and tumor biology. De-escalation strategies reducing the extent of surgery in the breast and axilla, aiming to minimize treatment-related morbidity (e.g., lymphedema, chronic pain, impaired mobility), while maintaining oncologic safety. This review synthesizes evidence from over 20 landmark trials, critically examines current clinical guidelines, and explores emerging technologies (e.g., artificial intelligence, liquid biopsy) that may further refine patient selection. We also highlight global disparities in adopting de-escalation strategies and discuss unanswered questions, such as applicability in high-risk subtypes and long-term recurrence risks.