Chinese Society of Breast Surgery (CSBrS) 2021 Guidelines: Breast-Conserving Surgery for Early-Stage Breast Cancer

Breast-conserving surgery (BCS)—removing cancer while preserving most of the breast—paired with radiotherapy is a gold-standard treatment for early-stage breast cancer. For Chinese patients and clinicians, clear, evidence-based guidelines are critical to ensuring safe, consistent care. In 2021, the Chinese Society of Breast Surgery (CSBrS) updated its 2019 consensus to create the Clinical Practice Guideline for BCS in Patients with Early-Stage Breast Cancer (2021 Version), led by 85 experts across disciplines. These guidelines prioritize patient choice, surgical precision, and long-term outcomes while standardizing care for Chinese breast specialists.

Who Developed These Guidelines?

The CSBrS panel includes 70 breast surgeons (82.3%), plus medical oncologists, diagnostic radiologists, pathologists, radiation oncologists, and epidemiologists—ensuring a multidisciplinary, authoritative approach. The guidelines are designed for Chinese clinicians specializing in breast diseases but offer valuable insights for anyone involved in early breast cancer care.

Who Is Eligible for BCS?

BCS is an option only if all of the following are true:

Patient choice: The patient must want to preserve their breast (backed by high-quality research).
Early-stage disease: Clinical Stage I, II, or tumors ≤cT2 (typically small to medium-sized tumors).
Cosmetic feasibility: The surgery must leave the breast with an acceptable appearance—no significant deformity.

When Is BCS Not Recommended?

BCS is unsafe or ineffective if any of these apply:

Cannot receive radiotherapy: Radiotherapy is critical to reducing recurrence risk—if a patient can’t undergo it (e.g., active connective tissue disease), BCS is not an option.
Positive surgical margins: If cancer cells remain at the edges of the removed tissue (even after reoperation), BCS cannot prevent recurrence.
Extensive microcalcifications: Widespread calcium deposits (seen on mammograms) may indicate hard-to-remove, diffuse cancer.
Inflammatory breast cancer: A rare, aggressive subtype where BCS is ineffective.
Patient refusal: BCS is always voluntary—if a patient prefers mastectomy, their choice is respected.

Key Surgical Tips for BCS

Surgeons should:

Use oncoplastic techniques: Combine cancer removal with plastic surgery to improve cosmetic results (backed by moderate evidence).
Place metal clips: Tiny titanium clips in the surgical bed help radiation oncologists target the tumor site accurately (high-quality evidence).

Pathology: Clear Margins Are Non-Negotiable

After BCS, checking if the tumor’s edges (margins) are free of cancer is mandatory. Here’s how it’s done:

Intraoperative frozen section: During surgery, a small sample is frozen and analyzed quickly—this reduces the need for second surgeries (high-quality evidence).
Post-op tissue analysis: Formalin-fixed, paraffin-embedded (FFPE) tissue is examined for final confirmation.
Preferred methods:
- Perpendicular inked method: The most reliable way to assess lumpectomy margins (high-quality evidence).
- Tangential shaved method: A secondary option for lumpectomy margins (moderate evidence).
- Cavity wall sampling: Tissue from the remaining breast cavity is checked to ensure no cancer is left (moderate evidence).

Radiotherapy After BCS: What You Need to Know

Whole-breast irradiation (WBI) is recommended for almost all patients (high-quality evidence)—it lowers the risk of cancer returning to the same breast. However:

Low-risk patients over 65: If you’re 65+, have Stage I, hormone receptor-positive cancer, and clear margins, you may skip WBI (based on the CALGB9343 trial). The 10-year recurrence risk is slightly higher (10% vs. 2% with RT), but survival is similar.

Timing and safety:

RT can be delayed until after chemotherapy (safe, per the International Breast Cancer Study Group Trials VI-VII).
Concurrent RT with endocrine therapy (e.g., letrozole) or anti-HER2 drugs (e.g., trastuzumab) does not increase side effects (backed by the CO-HO-RT and N9831 trials).

Why BCS + Radiotherapy Is Safe and Effective

Decades of research confirm BCS’s value:

NSABP B-06 trial: 20-year follow-up of 1,851 patients found no difference in survival between mastectomy, BCS alone, or BCS + radiotherapy.
Milan I trial: Women with small tumors (<2 cm) who had BCS + radiotherapy lived as long as those who had mastectomy—though recurrence was slightly higher (8.8% vs. 2.3%).
Chinese study: A short-term follow-up of 95 patients found a 1.4% 2-year local recurrence rate after BCS—no metastases or deaths.

For patients with larger tumors (Stage III or >T2), neoadjuvant chemotherapy can shrink the cancer to make BCS possible. While there’s no consensus on how much tissue to remove after chemo, clear margins remain mandatory.

Important Considerations for Clinicians

Recurrence risk factors: Factors like central tumors, nipple discharge, large tumors (>T2), multifocal cancer, young age (<35), or radiotherapy contraindications raise recurrence risk—but they are not formal contraindications to BCS (no high-quality evidence supports excluding patients for these reasons).
Avoid unproven methods: Intraoperative gross inspection (visual checks), imprint cytology (cell smears), or novel devices may reduce positive margins but lack high-quality evidence—stick to frozen section and FFPE analysis.

Final Takeaways

The 2021 CSBrS guidelines balance science with compassion: BCS is a safe, effective option for early-stage breast cancer if patients want it, the tumor is removable with clear margins, and radiotherapy is feasible. For patients, the key message is your choice matters—talk to your surgeon about whether BCS aligns with your goals. For clinicians, these guidelines provide a roadmap to deliver personalized, evidence-based care.

Source:
Chen K, Liu JQ, Wu W, et al. Clinical Practice Guideline for Breast-Conserving Surgery in Patients with Early-Stage Breast Cancer: Chinese Society of Breast Surgery (CSBrS) Practice Guidelines 2021. Chinese Medical Journal. 2021;134(18):2143–2146. doi:10.1097/CM9.0000000000001518

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