Continuing Evolution in Breast Cancer Surgical Management

The surgical management of primary breast cancer underwent significant evolution in the last quarter of the 20th century as a result of changes in the biologic understanding and clinical presentation of the disease. The proposal of an alternative hypothesis for the mechanism of tumor dissemination challenged the previously accepted Halstedian principles that had governed surgical management for the better part of that century. Randomized clinical trials were supportive of this alternative hypothesis and eventually established breast-conserving surgery plus radiotherapy as the preferred option for treating appropriate candidates with primary breast cancer. The alternative hypothesis was also supported by results from clinical trials indicating that the administration of adjuvant systemic therapy significantly improved disease-free and overall survival of patients with early-stage breast cancer. Adjuvant systemic therapy played an important role in the successful adoption of breast-conserving surgery plus radiotherapy by decreasing the rates of locoregional failure and by expanding the pool of candidates (by its use as preoperative or neoadjuvant therapy).