Omission of Surgery in Breast Cancer? Step Forward or Detour

My thoughts on Selective Elimination of Breast Surgery for Invasive Breast CancerA Nonrandomized Clinical Trial

The recent article by Kuerer et al. explores the possibility of omitting breast surgery in highly selected patients with triple-negative and ERBB2-positive breast cancer who achieve a pathological complete response (pCR) after neoadjuvant systemic therapy (NST). While the results of this phase 2 non-randomized trial are undoubtedly promising, they also raise several pertinent concerns.Over the years, breast cancer surgery has witnessed a steady evolution—from the era of Halsted’s radical mastectomy to modified radical mastectomy, then breast-conserving surgery (BCS), and now discussions around the omission of surgery altogether. This is a testament to our growing understanding of tumor biology, better imaging, systemic therapies, and individualised care. However, with this progress has also emerged a common misconception—particularly among non-surgical disciplines—that all breast surgeries are equally invasive and morbid. This misconception needs clarification that a simple wide local excision (WLE) for a small tumor, especially in a post-NST setting (mean tumor size in the trial was 0.81 cm), is not a radical or highly morbid procedure. It is often a straightforward day-care surgery with minimal morbidity. Equating such a conservative surgical approach to a radical intervention is neither accurate nor fair. Thus, replacing a small WLE with a 12-core vacuum-assisted biopsy (VAB) — essentially a minimally invasive sampling technique—does not necessarily represent a substantial improvement in patient comfort, procedural simplicity, logistical efficiency or accuracy (false negative rates - FNR). The Dutch MICRA study, which used intraoperative ultrasound-guided 14G core biopsy, demonstrated a FNR of 37%—rising to 55% in triple-negative and 71% in HER2-positive subtypes.We must ask: Is a 12-core VAB truly less inconvenient for the patient? Is it less time-consuming or less resource-intensive? Are we genuinely reducing morbidity or merely replacing one procedure with another that may not significantly improve patient experience or outcomes meaningfully? Or are we simply replacing a precise surgical approach with an equally resource-intensive radiologic procedure without demonstrable patient-centric benefits? Another argument often used against surgery is its perceived impact on cosmesis. However, in this very trial, at 5-year follow-up, there was a statistically significant increase in perceived asymmetry between breasts. The Breast Cancer Treatment Outcome Scale showed that cosmesis sub-scores worsened from a baseline mean of 1.1 to 1.8 at 5 years (P < .001). This raises a pertinent point that even VAB, followed by radiotherapy, is not immune to cosmetic concerns. On the contrary, surgery allows tailoring of the excision and closure to optimise cosmesis based on individual anatomy and patient preference—something a blind, imaging-guided biopsy cannot offer. Therefore, while the concept of surgical omission is intellectually appealing and aligned with the goals of surgical de-escalation, the practical implications need careful consideration. We must not compare apples with oranges: a small WLE is not equivalent to radical surgery, and VAB is not necessarily a less invasive or more patient or cosmetic-friendly alternative. Future trials should focus not just on oncologic outcomes, but also on patient experience, cost-effectiveness, accessibility, and long-term data before such a paradigm shift becomes clinical practice.