title: Over surgery in breast cancer.
abstract: Breast surgery remains the original and most effective 'targeted' therapy: excision of early cancer is curative and for more advanced disease surgery improves local disease control. However in well intentioned pursuit of cure and local disease control, some cancers are over-treated resulting in major physical and emotional morbidity. Less breast surgery is safe, as evidenced by steady reductions in mortality and local recurrence; earlier diagnosis and widespread use of systemic therapies and radiotherapy have allowed more conservative surgery. As tumour biology dictates cancer outcomes not surgery extent, surgery can safely be 'minimum required' rather than 'more is better' with the focus on removal of disease rather than healthy tissue. Surgeons can reduce the burden of surgery further but it is important that less surgery is not over-compensated by more radical or unnecessary systemic therapies and/or radiotherapy with their own toxicities and morbidity. We all need to be alert to the potential drivers of over treatment and over surgery such as failure to work within a multidisciplinary team, failure to design a multimodality treatment plan at diagnosis or overuse of novel assessment technologies of uncertain clinical utility. Pursuit of wide margins and the removal of the contra-lateral healthy breast for marginal risk-reduction gains are also to be discouraged as is routine local/regional surgery in stage 4 disease. The surgeon has a pivotal role in minimizing breast surgery to what is required to achieve the best oncological, functional and aesthetic outcomes.
authors.affiliation: Royal Marsden Hospital, Fulham Road, SW3 6JJ, London, UK. Electronic address: fiona.macneill@rmh.nhs.uk.
authors.forename: Fiona
authors.initials: F
authors.lastname: MacNeill
authors.affiliation: Section for Endocrine and Breast Surgery Department for Surgical Sciences Uppsala University Hospital, SE 751 85, Sweden. Electronic address: andreas.karakatsanis@surgsci.uu.se.
authors.forename: Andreas
authors.initials: A
authors.lastname: Karakatsanis
mesh_terms: D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000628:therapy*; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D015412:Mastectomy, Segmental / Q000379:methods; D000069342:Medical Overuse / Q000517:prevention & control*; D009361:Neoplasm Invasiveness; D010348:Patient Care Team; D018579:Patient Selection; D018714:Radiotherapy, Adjuvant; D012086:Reoperation
keywords: Breast cancer surgery; De-escalation of breast cancer surgery; Less is more; Overdoing surgery; Overtreatment; Personalised surgery