Breast cancer is the most common cancer affecting women worldwide. It is likely that many people reading this know someone who has been affected by this condition. For many, surgery remains the cornerstone of curative treatment. Breast cancer surgery has advanced significantly since the first radical mastectomies of the late 19th century to today’s refined breast-conserving and reconstructive techniques.
Surgery remains a key component of treatment of breast cancer. For early-stage disease, removing the tumour can be enough to eradicate cancer completely. In more advanced cases, surgery is complemented by chemotherapy, radiotherapy, and hormone therapy.
The success of breast cancer surgery has not happened by chance. It reflects decades of rigorous research, often led by surgeons. Trials that once compared radical mastectomy with breast-conserving surgery laid the foundations for a global shift in practice. Randomised studies in axillary surgery demonstrated that less can be more, avoiding major complications such as lymphoedema without compromising oncological standards. The surgical research forces driving this rapid development have changed lives. They also act as an exemplar for other specialties.
It is important that we continue to move forward. Surgical research remains underfunded compared to other areas of oncology. Questions that matter deeply to patients around recovery, long-term function, and how best to personalise surgery, are often left unanswered. As new treatments emerge, from immunotherapy to targeted drugs, the role of surgery continues to evolve. We need high-quality studies to define how and when surgery should be delivered in this changing landscape.
As we mark Breast Cancer Awareness Month, it is worth reflecting on what breast surgery has achieved, and the lessons we can learn from this. The journey from radical to tailored surgery demonstrates that progress comes from questioning, testing, and refining what we do, whilst challenging dogma.
BJS Academy has worked with BJS and BJS Open to identify some of the key papers published in our journals on this topic over the last year. We hope you find them informative.
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BJS highlights:
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BJS Commission on the surgical management of the axilla in breast cancer
Over the past 25 years, axillary management has moved from routine dissection to progressive de-escalation. Sentinel lymph node biopsy became the standard, and recent RCTs (SOUND, INSEMA) suggest that in selected patients even this step may be safely omitted. Completion dissection offers no survival benefit in limited nodal disease, shifting focus to reducing morbidity such as lymphoedema. After neoadjuvant therapy, sentinel node biopsy with or without targeted dissection is standard, while dissection is increasingly reserved for residual disease. Future directions include radiotherapy de-escalation, prophylactic lymphatic reconstruction, and new training approaches to deliver more individualized, less morbid care. Read the paper.
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Impact of postoperative complications and type 2 diabetes on breast cancer recurrence and mortality
This large Danish cohort of over 58,000 women with early-stage breast cancer showed that postoperative complications within 30 days were not associated with higher recurrence risk, but were linked to increased overall mortality. The effect was most striking in women with type 2 diabetes, where complications and diabetes together substantially increased the risk of death. These findings suggest that complications reflect poorer general health rather than drive recurrence, highlighting the importance of careful perioperative and comorbidity management. Read the paper.
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Clinical and patient-reported outcomes in women offered oncoplastic breast-conserving surgery as an alternative to mastectomy: ANTHEM multicentre prospective cohort study
In this UK multicentre study of 362 women explicitly offered a choice between OPBCS and mastectomy, most (81%) opted for OPBCS, with breast conservation achieved in ~94%. Complication rates were significantly lower after OPBCS than after mastectomy with reconstruction, and revision surgery was less common. Patient-reported outcomes were particularly favorable for therapeutic mammaplasty, which improved breast satisfaction and psychosocial well-being compared with mastectomy, while chest wall perforator flaps and reconstruction tended to maintain baseline outcomes. OPBCS emerges as a safe, patient-preferred, and quality-of-life–enhancing alternative when technically feasible. Read the paper.
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BJS Open highlights:
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Breast Satisfaction and Quality of Life After Different Surgical Strategies in Japanese Patients
This large multicentre cross-sectional study compared health-related quality of life (HR-QoL) across mastectomy, breast-conserving surgery (BCS), and immediate breast reconstruction (IBR) in 577 Japanese women. Using the BREAST-Q, it found that BCS achieved the highest satisfaction with breasts, followed by IBR and mastectomy. Both BCS and IBR also showed significantly better psychosocial and sexual well-being compared to mastectomy, while physical well-being was similar across groups. These findings emphasize the need for thorough preoperative counselling, highlighting how surgical choice impacts long-term quality of life and patient satisfaction. Read the paper.
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Impact of Surgical Method on Capsular Contracture After Risk-Reducing Mastectomy
A national register-based cohort from Sweden investigated 1095 implant-based breast reconstructions after risk-reducing mastectomy. The cumulative 5-year incidence of severe capsular contracture requiring surgery was 4.7%, but was significantly higher for permanent tissue expanders (10.8%) compared to fixed-volume implants (1.7%). Permanent expanders were independently associated with a 19-fold increased hazard of contracture. These data support long-term follow-up and careful selection of implant type in women undergoing preventive mastectomy. Read the paper.
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Predicting Axillary Macrometastases to Guide Radiotherapy in Breast Cancer
This Swedish nationwide registry study developed and validated preoperative prediction models to estimate the likelihood of sentinel lymph node macrometastases (macro-SLNMs) in patients with clinically node-negative (cN0) breast cancer. Using adaptive LASSO regression on over 18,000 cases, the models achieved solid discriminatory power (AUCs 0.708–0.740) and offered individualized risk estimates ranging from 1.6% to 74.6%. These models align with current PMRT guidelines and ongoing de-escalation trials, offering clinicians a robust tool for stratifying patients before surgery. They support informed decisions about postmastectomy radiotherapy and immediate breast reconstruction by anticipating axillary burden. Read the paper.
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Oncoplastic Breast-Conserving Surgery Yields Superior Survival Compared to Mastectomy
This large population-based study from Scotland analyzed over 14,000 breast cancer patients to assess long-term outcomes after different surgical approaches. After adjusting for tumor stage, biology, and socioeconomic status, oncoplastic breast-conserving surgery (OBCS) followed by radiotherapy was associated with significantly better overall and breast cancer–specific survival compared to mastectomy ± radiotherapy. Subgroup analyses confirmed these findings in both screen-detected and symptomatic cancers. The results support the oncological safety and survival benefit of breast-conserving strategies with aesthetic preservation in modern multidisciplinary breast cancer care. Read the paper.
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High-Impact Complications After Breast Cancer Surgery: Do We Need Case-Mix Adjustment?
Using data from over 32,000 patients in the Dutch Breast Cancer Audit, this study evaluated whether case-mix adjustment is needed when benchmarking hospital complication rates. It found that surgical type (e.g. mastectomy with/without reconstruction vs. breast-conserving surgery) had a much stronger influence on complication rates than patient-related factors. Once stratified by procedure type, hospital rankings remained largely unchanged even without adjustment. The authors suggest that benchmarking should be stratified by procedure rather than rely on complex case-mix models. Read the paper.
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