Chinese breast cancer surgery: clinical practice and research

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Chinese breast cancer surgery: clinical practice and research Ling Xin¹, Jia-Yi Li¹, Zhi-Gang Yu², Yin-Hua Liu¹
¹Breast Disease Center, Peking University First Hospital, Beijing 100034, China; ²Breast Surgical Department, The Second Hospital of Shandong University, Jinan, Shandong 250000, China

Breast cancer is the most common cancer in women worldwide, impacting over 2 million new patients in 2018 alone, according to the International Agency for Research on Cancer’s (IARC) GLOBOCAN database. That year, it caused 600,000 deaths globally—an age-standardized rate (ASR) of 13 per 100,000 women. In China, the burden is growing even faster: 270,000 new cases were diagnosed in 2015, rising to 367,900 by 2018. This surge highlights an urgent need for evidence-based care and research tailored to Chinese patients.

A Century of Progress: From Radical Surgery to Patient-Centered Care

The evolution of breast cancer surgery reflects a shift from “cure at all costs” to balancing survival with quality of life. In 1894, surgeon William Halsted introduced radical mastectomy—removing the entire breast, chest muscles, and underarm lymph nodes. For the first time, this achieved R0 resection (complete tumor removal with no cancer cells at the edges), pushing 5-year survival above 40%. But as we learned breast cancer spreads systemically (via blood or lymph), the downsides of radical surgery—permanent physical changes, reduced mobility—became impossible to ignore.

By the 20th century, landmark trials transformed care. The U.S.-led National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04, B-06, and B-32 trials proved that breast-conserving surgery (BCS)—removing only the tumor and a small margin of healthy tissue—plus radiation offers the same survival as mastectomy for early-stage cancer. Similarly, sentinel lymph node biopsy (SLNB)—testing the first lymph node cancer might spread to—avoided the lymphedema (arm swelling) caused by full underarm dissection (ALND) in most patients with negative nodes. The core goal—R0 resection—remained, but now with a focus on preserving what matters most to patients: their bodies and their lives.

Personalized Care: Molecular Subtypes and Modern Surgery

Since the 2000s, molecular subtypes (based on proteins like estrogen receptor, progesterone receptor, and HER2) have revolutionized treatment. For example:

  • HER2-positive cancer: Targeted drugs like trastuzumab drastically improve outcomes.
  • Triple-negative cancer: Immunotherapy or chemotherapy may be used.
  • Hormone receptor-positive cancer: Endocrine therapy (e.g., tamoxifen) is key.

Better radiotherapy also lets surgeons plan procedures more precisely—reducing radiation doses to healthy tissue while killing remaining cancer cells. Still, critical questions linger:

  • Is it safe to skip ALND if the sentinel node has a small amount of cancer?
  • What counts as a “clear margin” for BCS after neoadjuvant chemotherapy (chemotherapy before surgery)?
  • How safe is SLNB for patients whose lymph nodes were positive before neoadjuvant therapy?

China’s Focus: Standardization and Adapting Global Evidence

In China, surgeons are tackling two priorities: standardizing care and adapting global evidence to local realities. Key areas of focus include:

1. Core Needle Biopsy (CNB)

CNB—a minimally invasive way to diagnose breast lesions—is recommended by the National Comprehensive Cancer Network (NCCN) for suspicious masses. Yet many smaller hospitals still use open biopsy (a larger incision), delaying personalized care. To address this, the Chinese Society of Breast Surgeons (CSBrS)—founded in 2017 with members from 41 major hospitals—released a 2019 guideline on ultrasound-guided CNB to raise awareness of its benefits, like better surgical planning and fewer second operations.

2. Sentinel Lymph Node Biopsy (SLNB)

Most Chinese surgeons lack certification to use radionuclides (radioactive tracers) for SLNB. Instead, they use methylene blue or carbon nanoparticles to find sentinel nodes—a practical solution for local settings. CSBrS’s 2018 guideline standardizes this approach, ensuring safety and accuracy.

3. Breast-Conserving Surgery (BCS)

Despite evidence that BCS is safe and cosmetically better for early-stage cancer, only 30% of eligible Chinese patients receive it. CSBrS’s 2019 BCS guideline clarifies who qualifies (e.g., small tumors, no widespread disease) and how to perform it—aiming to boost uptake.

4. Vacuum-Assisted Breast Biopsy (VABB)

For benign lesions (non-cancerous), VABB uses a small incision and suction to remove tissue accurately. CSBrS’s 2017 guideline promotes this technique to minimize invasive surgery.

The Role of CSBrS: Leading Standardization and Research

CSBrS’s mission is to align Chinese care with global best practices while addressing local challenges. By May 2020, the society had released 10 guidelines on topics like CNB, SLNB, BCS, and VABB. It also launched 10 multi-center studies by 2019—investigating questions like BCS outcomes in Chinese patients or the safety of methylene blue for SLNB.

A key principle: oncologic safety first. For breast reconstruction (offered to most mastectomy patients per NCCN guidelines), CSBrS emphasizes that no reconstruction is worth doing if cancer remains. Successful care requires a team—surgeons, oncologists, plastic surgeons—to balance appearance with cure.

Looking Ahead: Research and Adaptation

As breast cancer rates rise in China, CSBrS’s work is more critical than ever. Its guidelines help surgeons navigate local barriers—like using methylene blue for SLNB when radionuclides are unavailable—while upholding global standards. Multi-center studies will also answer questions unique to Chinese patients: How does BCS work in women with dense breasts? What’s the best way to treat HER2-positive cancer in resource-limited settings?

The goal is clear: Provide Chinese breast cancer patients with care that’s both cutting-edge and compassionate—proving that survival and quality of life don’t have to be mutually exclusive.

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