The future of surgery in the treatment of breast cancer

The role of surgery cannot be discussed independently, but in relationship to the other modalities of treatment. Sentinel lymph node mapping and biopsy has revolutionized the role of surgery in axillary staging. Techniques of sentinel node mapping, the timing relative to chemotherapy, possible contraindications, and the necessity of completion axillary dissection are all under active investigation. The next few years will see continued changes in this important technique. Techniques of localizing clinically occult tumors are numerous and under study. These are not yet at the level of Phase III comparative trials. Induction chemotherapy has long been standard care for women with locally advanced breast cancer. It has not become standard care for Stage I or II breast cancers that meet criteria for adjuvant therapy. The ability to significantly downsize 80% of breast cancers is reason enough to make it usual practice for women who are certain to receive chemotherapy, if only for the cosmetic advantage that would accrue. Much has been made of the use of thermal ablation of small breast cancers by small probes introduced by skin puncture. In initial trials the lesions were excised after being heated or frozen. Current studies are leaving the destroyed tissue in place and following for evidence of control or recurrence. The value of this approach in terms of cosmesis is unproven, and the timing of its introduction when small tumors are being evaluated for margins and genetic markers, make it difficult to imagine broad acceptance. Finally, the role of prophylactic surgery for women at increased risk remains a difficult equation, compounded of alternatives such as chemoprevention, availability and effectiveness of surveillance techniques, and the level of fear and anxiety of the patient.