Breast cancer treatment de-escalation: breaking the SOUND barrier

Abstract

Breast Cancer (BC) is the leading oncological diagnosis, with the annual incidence expected to exceed 3 million new cases by 2040 due to population growth and ageing. Despite the increasing number of BC patients, recent advancements in multidisciplinary treatment have enabled surgical de-escalation, maintaining equivalent oncological outcomes. Areas of surgical de-escalation include avoidance of axillary lymph node dissection in patients with low disease burden, re-excision in close margins after breast conserving surgery, and even complete avoidance of surgery in selected cases. Despite the evidence supporting these de-escalation protocols, their implementation is inconsistent. The article discusses how these strategies can be further integrated into BC treatment plans to improve patients' quality of life and optimize health care resources. The future of BC management may be shaped by genomic tests, offering more tailored and potentially less invasive treatment strategies. A comprehensive understanding of tumor biology has facilitated the development of strategies such as neoadjuvant chemotherapy, with the potential to further de-escalate surgery. The need for a multidisciplinary approach to BC care, incorporating emerging diagnostic tools and understanding of individual patient's disease trajectory, is paramount. It is essential to challenge the perception of more aggressive treatments as inherently better and ensure decisions are based on high-quality evidence, preserving the principle of 'do no harm'. The focus of future BC research should be on identifying markers capable of predicting the risk of distant recurrence and implementing a true multidisciplinary de-escalation approach.

Keywords

• breast neoplasms
• quality of life
• surgery
• mastectomy
• segmental
• precision medicine