Real de-escalation or escalation in disguise?

The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.

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Déclaration de conflit d'intérêts

Declaration of competing interest Maggie Banys-Paluchowski received honoraria for lectures and participation in advisory boards from: Roche, Novartis, Pfizer, pfm, Eli Lilly, Onkowissen, Seagen, AstraZeneca, Eisai, AstraZeneca, Amgen, Samsung, Canon, MSD, GSK, Daiichi Sankyo, Gilead, Sirius Pintuition, Pierre Fabre, ExactSciences, and study support from: EndoMag, Mammotome, MeritMedical, Gilead, Sirius Pintuition, Hologic. Thorsten Kühn received honoraria from: Merit Medical, Endomagnetics, Hologic, Sirius Medical, Pfizer, MSD, Astra Zeneca, Daiichi Sankyo, Exact Sciences and study support from: Mammotome, Merit Medical, Sirius Medical, Endomagnetics, Hologic. David Krug has received honoraria from Merck Sharp & Dohme and Pfizer as well as research funding from Merck KGaA. Nina Ditsch received honoraria from: AstraZeneca, BLÄK, Daiichi-Sankyo, if-Kongress München, Leopoldina Schweinfurt, Lilly, Lukon, Molekular Health, MSD, onkowissen, Pfizer, RG Ärztefortbildungen, Roche, Seagen, UKA, BZKF Förderung, SerMA pilot Universität Augsburg. Other authors declare no conflicts of interest.