Treating Early Breast Cancer: Can We Do Less Without Compromising Outcomes?
From Less Extensive Surgery to More Personalized Radiotherapy and Systemic Treatment
Advances in breast cancer research are helping clinicians identify which patients may benefit from less intensive treatment and which need additional protection against recurrence. Dr. Muneera Al Hussaini, Consultant, Oncology and Hematology at SMC Healthcare, discusses how tumour biology, clinical evidence and multidisciplinary expertise inform decisions about surgery, lymph-node assessment, radiotherapy and chemotherapy. The aim is to tailor care to each patient while carefully weighing the benefits and risks of every treatment option.
Breast cancer treatment has traditionally been very aggressive. Are we now entering an era in which some patients can safely receive less treatment?
Yes, and this is one of the most meaningful changes in breast cancer care and a sought-after goal in breast cancer research. We now recognize that early breast cancer is a group of heterogeneous diseases that differ in risk and treatment needs. Giving every woman the same treatment can expose some patients to unnecessary side effects with limited additional benefit.
For appropriately selected women, we can preserve the breast, reduce lymph-node surgery, and shorten or avoid radiotherapy and/or chemotherapy. These options are supported by clinical trials. The goal is to maintain excellent cancer outcomes while reducing the physical and emotional burden of treatment.
Which patients with early-stage breast cancer may be candidates for treatment de-escalation?
The clearest examples are women with small, hormone receptor-positive, HER2-negative cancers, particularly when the tumour is lower grade and there is no evidence of lymph-node involvement. In some situations, a favourable genomic test result provides a more accurate prediction that chemotherapy would offer little benefit.
However, eligibility depends on which treatment we are considering reducing. A woman may safely avoid chemotherapy but still benefit from radiotherapy, or qualify for less lymph-node surgery while still needing systemic treatment. For optimal treatment planning, we consider tumour biology, stage, age, menopausal status, overall health and the patient’s preferences together. Age alone is never enough to make the decision.
How has breast-conserving surgery evolved, and when can it provide outcomes comparable to mastectomy?
Many women understandably feel that removing the whole breast must give them a better chance of survival. However, long-term randomized trials have shown that, for suitable early breast cancers (e.g., based on size and location), breast-conserving surgery followed by appropriate radiotherapy provides survival comparable to mastectomy.
Surgical techniques have also improved. Oncoplastic surgery combines cancer removal with reshaping of the breast, allowing more women to preserve their breast with an acceptable cosmetic result. Treatment before surgery can sometimes shrink a tumour enough to make breast conservation possible.
The key is whether we can remove the cancer with clear margins and provide the additional treatment needed. Mastectomy remains appropriate in some circumstances, but more extensive surgery does not automatically mean better cancer control or longer survival.
Is sentinel lymph-node biopsy still necessary for every patient with early breast cancer, or can it now be safely omitted in selected cases?
It can now be omitted in selected patients. Sentinel lymph-node biopsy is less invasive than a full axillary dissection, but it can still cause pain, numbness, restricted shoulder movement and lymphoedema.
The SOUND and INSEMA trials have helped establish that some women with small cancers and a clinically negative axilla can avoid surgical lymph-node staging. The 2025 ASCO (American Sosciety of Oncology) guideline supports omission in selected postmenopausal women aged 50 or older who have a tumour no larger than 2 cm, grade 1 or 2, hormone receptor-positive, HER2-negative disease, reassuring axillary ultrasound findings and planned breast-conserving treatment.
