The Role of Surgery in Managing Primary and Metastatic Breast Cancer

Modern breast cancer surgery began with Dr. William Halsted’s hypothesis that breast cancer spreads in a stepwise fashion from local to regional to distant sites and his description of the radical mastectomy in 1894. With the introduction of antineoplastic chemotherapy and radiation therapy, and improved knowledge of the biology and behavior of breast cancer, the treatment of breast cancer has evolved substantially. It is now understood that breast cancer metastasis is driven by tumor biology, hence en bloc resection does not improve outcomes over operations that extirpate cancer while minimizing sacrifice of normal tissue. In turn, efficacious new systemic therapies, including biologically targeted therapies, permit further de-escalation of surgical therapy. For patients presenting with an intact primary breast tumor and synchronous distant metastases, recent data suggest that surgery for the primary site does not improve overall survival, providing further evidence that tumor biology cannot be overcome by surgery.