Chinese Breast Cancer Surgery: Clinical Practice and Research
Breast cancer remains the most commonly diagnosed cancer among women globally, as highlighted by the GLOBOCAN 2018 statistics from the International Agency for Research on Cancer. In 2018, over 2 million new cases were reported worldwide, with an age-standardized rate (ASR) of 46.3 per 100,000, and more than 600,000 deaths were attributed to the disease, with an ASR of 13.0 per 100,000. In China, the burden of breast cancer has been steadily increasing, with 270,000 new cases diagnosed in 2015 and 367,900 new cases reported in 2018. This alarming rise underscores the urgent need for advanced clinical research and expert consensus on optimal therapies for breast cancer.
The evolution of breast cancer surgery has been shaped by clinical evidence and advancements in medical understanding. The 19th century marked the beginning of modern breast cancer surgery with Halsted’s radical mastectomy, which involved the removal of the pectoralis major and minor muscles along with axillary and subclavian lymphadenectomy. This procedure achieved local R0 resection of tumors and a 5-year survival rate exceeding 40%. However, the necessity of such radical procedures was later challenged with the emergence of systemic disease concepts and systemic therapies. The adverse impact of radical mastectomy on patients’ quality of life led to its gradual abandonment in the 20th century, paving the way for breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). These techniques, supported by high-level evidence, became the preferred options for early-stage breast cancer treatment, emphasizing both survival and quality of life. Despite these changes, the fundamental principle of achieving R0 resection of the primary tumor and regional lymph nodes remains unchanged.
The National Surgical Adjuvant Breast and Bowel Project (NSABP), launched in 1971 by the United States, Canada, and Australia, played a pivotal role in standardizing breast and bowel cancer treatment through prospective, multi-center clinical studies. Trials such as NSABP B-04, B-06, and B-32 provided robust evidence supporting BCS and SLNB, which significantly improved surgical techniques for breast cancer. In 2020, the National Comprehensive Cancer Network (NCCN) further clarified the indications and contraindications for BCS, SLNB, and breast reconstruction surgery. However, debates persist regarding the optimal surgical margins for BCS, the management of limited sentinel lymph node (SLN) metastasis, and the utility of SLNB in node-positive patients after neoadjuvant systemic chemotherapy (NST).
The 21st century ushered in the era of molecular subtypes, which have been instrumental in developing individualized treatments for breast cancer. Beyond surgical tumor reduction, advancements in cytotoxic, endocrine, targeted, and immune therapies have enabled personalized treatment strategies based on molecular subtypes. Improved radiotherapy techniques have also allowed surgeons to refine breast surgery plans to maximize patient benefits while minimizing harm. Nevertheless, the safety of omitting axillary lymph node dissection (ALND) in patients with positive SLNs, the definition of clear margins in BCS after NST, and the safety of SLNB in node-positive patients post-NST remain contentious issues.
In China, the standardization of breast cancer surgical procedures is a primary concern among surgeons. Techniques such as core needle biopsy (CNB), BCS, breast reconstruction, and vacuum-assisted breast biopsy (VABB) are being increasingly adopted. However, challenges such as the lack of radionuclide certification among surgeons and patients’ reluctance to undergo second operations have led to the preference for single lymphatic techniques for SLN localization and frozen pathological diagnosis for margin assessment. To address these issues, Chinese doctors are encouraged to enhance clinical standardization and conduct multi-center studies based on global research findings and domestic conditions.
The Chinese Society of Breast Surgeons (CSBrS), established in 2017, has been instrumental in standardizing breast cancer treatment and fostering multi-center research. By May 2020, the CSBrS had issued ten guidelines on critical topics in breast cancer. The 2013 St. Gallen Consensus marked a significant milestone in personalized breast cancer treatment by incorporating molecular subtypes into evidence-based treatment recommendations. Despite the NCCN’s strong endorsement of CNB for suspicious lesions, many primary and even some large general hospitals in China still rely on open biopsy and intra-operative frozen pathological examination for mastectomy decisions, hindering progress in personalized early-stage breast cancer treatment. To raise awareness and promote CNB, the CSBrS published consensus statements and operation guidelines on ultrasound-guided breast lesion and lymph node biopsy in 2019.
For patients diagnosed with benign lesions through CNB, the goal is to minimize invasive surgery. VABB, known for its accuracy, convenience, and minimal incision, has been promoted through CSBrS guidelines published in 2017. For patients with cancerous lesions identified via CNB, the focus is on maximizing quality of life while providing effective treatment. The NSABP-B32 trial demonstrated that patients with clinical lymph node-negative breast cancer could safely avoid ALND and lymphedema if SLNs were negative. In China, where radionuclide and isosulfan blue are often unavailable, methylene blue or carbon nanoparticles are commonly used for SLN localization. To standardize SLNB in early-stage breast cancer, the CSBrS published guidelines in 2018. Despite the known safety and aesthetic benefits of BCS for selected early-stage breast cancer patients, the adoption rate in China remains below 30%. To address this, the CSBrS issued a consensus statement on BCS in 2019, clarifying its indications, contraindications, and surgical techniques.
Breast reconstruction is another critical aspect of breast cancer treatment. According to NCCN guidelines, all breast cancer patients, especially those requiring mastectomy, should receive pre-surgical consultation on reconstruction options. However, oncologic safety remains paramount, ensuring that reconstruction does not interfere with the timing of oncological surgery and surveillance. Successful reconstruction requires multidisciplinary teamwork and must not compromise the removal of residual tumors.
The rapid development of oncology has led to the establishment of independent breast surgery departments in both cancer and general hospitals across China. This progress has enabled the initiation of domestic multi-center clinical studies. By 2019, ten multi-center studies on trending breast cancer topics had been launched, with more planned for 2020. The CSBrS continues to drive the development and standardization of breast cancer clinical treatment in China.
doi.org/10.1097/CM9.0000000000000992
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