Modern surgical treatment of breast cancer

Abstract

Breast cancer is the most frequent cancer in women all over the world. The prognosis is generally good, with a five-year overall survival rate above 90% for all stages. It is still the second leading cause of cancer-related death among women. Surgical treatment of breast cancer has changed dramatically over the years. Initially, treatment involved major surgery with long hospitalization, but it is now mostly accomplished as an outpatient procedure with a quick recovery. Thanks to well-designed retrospective and randomly controlled prospective studies, guidelines are continually changing. We are presently in an era where safely de-escalating surgery is increasingly emphasized. Breast cancer is a heterogenous disease, where a "one-size-fits-all" treatment approach is not appropriate. There is often more than one surgical solution carrying equal oncological safety for an individual patient. In these situations, it is important to include the patient in the treatment decision-making process through well informed consent. For this to be optimal, the physician must be fully updated on the surgical options. A consequence of an improved prognosis is more breast cancer survivors, and therefore physical appearance and quality of life is more in focus. Modern breast cancer treatment is increasingly personalized from a surgical point of view but is dependent on a multidisciplinary approach. Detailed algorithms for surgery of the breast and the axilla are required for optimal treatment and quality control. This review illustrates how breast cancer treatment has changed over the years and how the current standard is based on high quality scientific research.

Keywords: Breast cancer; Oncoplastic surgery; Surgical algorithms; Surgical treatment of breast cancer.

Fig. 1

A flowchart illustrating the current guidelines in Norway (https://www.helsebiblioteket.no/retningslinjer/brystkreft/kirurgisk-og-kurativ-behandling/kirurgisk-taktikk-og-teknikk/flytskjema-for-brystkirurgiske-alternativ). There are many steps. Most decisions are made by a multidisciplinary team consisting of radiologists, pathologists, oncologists, and breast surgeons. In some cases, there are plastic surgeons involved. It is important to include the patients in the decisions in cases where the different available options are equivalent in terms of prognosis.

Fig. 2

Flowchart for surgery in the axilla in cases where patients are treated with primary surgery. BCT, breast conserving therapy. SLND, sentinel lymph node dissection. SLN, sentinel lymph node. ALND, axillary lymph node dissection (Burstein, Curigliano et al., 2019).

Fig. 3

Flowchart for surgical treatment of the axilla in neoadjuvant treated patients. cN, clinical nodal status. pN, pathological nodal status. SLNB, sentinel lymph node biopsy. ALND, axillary lymph node dissection. NST, neoadjuvant systemic therapy. Patients with pN2 or pN3 are advised to have a ALND. * SLNB with certain recommendations; SLNB + > 2 resected lymph nodes. Dual tracing. Histological examination with H&E and IHC. Metastases >0,2 mm warrant ALND. In some institutions targeted axillary dissection (TAD) is advised. ** In these cases, ALND can be omitted provided the above recommendations. When there is doubt, ALND is advised (Burstein, Curigliano et al., 2019).