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With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.

The heterogeneous nature of ductal carcinoma in situ has been emphasised by data for breast-cancer screening that show substantial increases in the detection of early-stage non-invasive breast cancer but no noteworthy change in the incidence of invasive and distant metastatic disease. Indolent non-progressive forms of ductal carcinoma in situ are managed according to similar surgical strategies as high-risk disease, with extent of resection dictated by radiological and pathological estimates of tumour dimensions. Although adjuvant treatments might be withheld for low-risk lesions, surgical treatments incur potential morbidity, especially when mastectomy and breast reconstruction are done for widespread low-grade or intermediate-grade ductal carcinoma in situ. Low rates of deaths from breast cancer coupled with overdiagnosis within screening programmes have prompted a fundamental rethink of approaches to the management of both low-risk and high-risk ductal carcinoma in situ. Changes include active surveillance for low-risk lesions and a watchful waiting policy with intervention when invasive local recurrence after breast-conserving surgery is detected. Prediction of ipsilateral invasive recurrence is likely to be improved by integration of molecular biomarkers with conventional histopathological parameters. Moreover, further genetic interrogation of ductal carcinoma in situ might lead to a reclassification of some low-grade lesions as non-cancerous entities.

Ductal carcinoma in situ (DCIS) constitutes a major public health problem, with up to half of screen-detected cancers representing pure forms of DCIS without evidence of invasion. A proportion of cases detected with routine screening would not have progressed to a life-threatening form of breast cancer during the patient's lifetime, and overdiagnosis of breast cancer is a cause for concern. Once DCIS has been detected, treatment is obligatory and present technologies do not allow accurate risk stratification such that intensity of treatment can be tailored to risk of recurrence and progression to invasive disease. Present management strategies are based on prognostic and predictive information derived from conventional histopathological and host factors. With increasing molecular characterisation of these preinvasive lesions, data will be available for how factors such as oestrogen receptor, progesterone receptor, HER2, and indicators of proliferative activity can provide additional information about both prognosis and benefit from adjuvant treatments such as radiotherapy and hormonal therapy. Low-risk patients are especially poorly defined in terms of need for adjuvant therapies, which can be associated with both short-term adverse sequelae and long-term effects (eg, cardiotoxicity) that can affect all-cause mortality. Optimum risk prediction in the future is likely to be achieved by integration of both conventional and molecular factors, which should be incorporated into a validated predictive model to help with clinical decision making.

Non-surgical ablation is emerging as an alternative local therapy option for patients with early-stage breast cancer and encompasses two main types of percutaneous therapeutic procedures: radiofrequency ablation and cryoablation. Both techniques involve obliteration of a spherical lesion and feasibility studies have shown that complete tumour ablation is achievable with good or excellent cosmetic results. Although few clinical studies have directly compared non-surgical ablation with conventional surgical resection, observational studies indicate that clinical outcomes are favourable with acceptable rates of local control and no detriment to long-term survival. There remain outstanding issues with these percutaneous ablative techniques that require resolution before they could be incorporated into routine clinical practice. Hence, a consensus meeting was convened to discuss the challenges of non-surgical ablation and clarify indications for its use alongside clinical management pathways. In this Policy Review we will address some of the broader biological aspects of non-surgical ablation, including immune-modulatory effects and potential novel applications for the future.

Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

Adoption of urbanised lifestyles together with changes in reproductive behaviour might partly underlie the continued rise in worldwide incidence of breast cancer. Widespread mammographic screening and effective systemic therapies have led to a stage shift at presentation and mortality reductions in the past two decades. Loco-regional control of the disease seems to affect long-term survival, and attention to surgical margins together with improved radiotherapy techniques could further contribute to mortality gains. Developments in oncoplastic surgery and partial-breast reconstruction have improved cosmetic outcomes after breast-conservation surgery. Optimum approaches for delivering chest-wall radiotherapy in the context of immediate breast reconstruction present special challenges. Accurate methods for intraoperative assessment of sentinel lymph nodes remain a clinical priority. Clinical trials are investigating combinatorial therapies that use novel agents targeting growth factor receptors, signal transduction pathways, and tumour angiogenesis. Gene-expression profiling offers the potential to provide accurate prognostic and predictive information, with selection of best possible therapy for individuals and avoidance of overtreatment and undertreatment of patients with conventional chemotherapy. Short-term presurgical studies in the neoadjuvant setting allow monitoring of proliferative indices, and changes in gene-expression patterns can be predictive of response to therapies and long-term outcome.

There are estimates suggesting that anywhere from 0 to 54% of all breast cancers may represent overdiagnosed disease in parts of the world where mammography screening programs are in place (16-19). [...]breast cancer overdiagnosis consequent to mammography screening is a major public health concern. [...]for many women with screen-detected breast cancers, survival would not have been impaired in the absence of screening and they would never have known that they had breast cancer (i.e.,screening resulted in breast cancer overdiagnosis). [...]some asymptomatic, screen-detected cancers may progress quickly enough to become life-threatening, but the patient may die of other causes before the malignancy becomes clinically apparent (i.e.,have a personal survival from breast cancer). Yet, as mentioned previously, this has not been associated with subsequent declines in incidence of patients presenting with advanced metastatic breast cancer. [...]rates of invasive breast cancer in elderly women following cessation of screening do not decline to rates below those expected for age-matched cohorts who do not undergo screening (27).

Most studies included in this systematic review were underpowered with small numbers of patients and relatively short follow-up. [...]the majority employed standard BCS techniques (rather than oncoplastic surgery) with limited application of modern adjuvant treatments. Furthermore, rates of both local recurrence (p<0.001) and distant metastases (p<0.003) were increased for MIBC patients with the conclusion that multifocality and multicentricity were significant predictors for reduced overall survival (p=0.016), local relapse (p=0.081) and distant metastases (p=0.038). [...]the number of tumor foci appears to be an independent prognostic factor and TNM staging for multifocal and multicentric tumors should be re-evaluated in terms of the T-category. At a median follow-up of 7.9 years, cumulative 10 years local recurrence rates were similar for MIBC and unifocal cancers undergoing both BCS and mastectomy (Table 1). [...]multifocality and multicentricity were not significant risk factors for local relapse nor impaired survival (matched analysis of MIBC vs unifocal cancers [p=0.60]). Oncoplastic breast surgery and multiple ipsilateral breast cancers Oncoplastic procedures permit wide resection of tissue with tumor-free margins and provide adequate rates of local control of disease, good cosmetic outcomes and improved quality of life. [...]mean tumor size is higher for oncoplastic than standard BCS (2.7 vs 1.2cm), margin positivity rates are lower (12 vs 21%; p<0.001) and fewer re-excisions are performed (4 vs 14.6%) (18,19).

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory condition of the breast which although benign can mimic carcinoma. Establishing a diagnosis can be challenging and requires a high index of suspicion with exclusion of infective and autoimmune breast diseases. IGM is characterized histologically by noncaseating granulomas which are of a lobulo-centric pattern and often associated with microabscess formation. Management of confirmed cases remains controversial with proponents of initial surgical or medical therapies - each has its associated problems which can be worse than the original symptoms of IGM. However, many patients require more than one modality of treatment to completely resolve IGM lesions and careful judgment is necessary to ensure optimal type and sequencing of treatments.

Breast cancer now represents the most common female malignancy in both the developing and developed world, and is the primary cause of death among women globally. Despite well-documented reductions in mortality from breast cancer during the past two decades, incidence rates continue to increase and do so more rapidly in countries that historically had low rates. This has emphasized the importance of survivorship issues and optimal management of disease chronicity. This article reviews current trends of incidence and mortality in both a western and global context, and considers pertinent changes in underlying etiological risk factors. The latter not only offer clues regarding changes in incidence patterns, but also provides rationale and guidance for strategies that could potentially reduce the burden of this disease. The relevance of lifestyle adjustments and screening interventions for primary and secondary prevention, respectively, are discussed with reference to different healthcare resource settings.