Current weaknesses of breast conserving strategies after neoadjuvant chemotherapy in breast cancer treatment

Locally advanced breast cancer (LABC) represents a worldwide major challenge, with a reported incidence reaching up to 90%. In such setting, current guidelines advise for neoadjuvant chemotherapy (NACT) as primary approach to provide effective systemic treatment while surgically down-staging the cancer at presentation. Despite advantages of NACT, ranging a reported locoregional response rate from 30% to 70%, several national surveys still describe higher mastectomy rates than expected. This phenomenon can be ascribed to radiology related factors, as the role of magnetic resonance imaging (MRI), despite having the highest correlation coefficient to final pathology, may still underestimate and overestimate tumor size, leading to surgical over and under treatment; surgeon related factors, as many breast surgeons routinely perform surgery based on pre-treatment characteristics rather than more appropriate post-treatment imaging and clinical results; patient related factors, as there is a well-documented tendency to prefer mastectomy instead of breast conservation therapy (BCT), in an attempt to reach better oncologic outcomes and hospital related factors, as there is too much variability between breast cancer centers, offering modern and minimally-invasive treatments and general hospitals, reporting a difficult access to advanced breast conserving strategies. In this context, the major part of this disinformation sequence in played by an important lacking of strong evidences, mostly regarding the oncologic outcomes of breast conserving surgery (BCS) and oncoplastic surgery (OS). Some recent high impact papers are reporting benefits of OS in LABC treatment, extending beyond improving cosmetic results, to the possibility of obtaining wider excisions with similar oncologic results as observed in patients submitted to classic BCS and mastectomy. Furthermore, what emerges from LABC literature is an imperative need of multidisciplinary breast centers worldwide diffusion, where breast-dedicated oncologists, radiologists and oncoplastic surgeons can offer patient-centered updated diagnostics, treatment protocols and surgical solutions, especially in a very delicate scenario, such as LABC treatment.