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Review

Addressing the problem of overtreatment in breast cancer

& ORCID Icon
Pages 535-548 | Received 10 Jan 2022, Accepted 06 Apr 2022, Published online: 19 May 2022

References

  • Welch HG, Prorok PC, O’Malley AJ, et al. Breast-Cancer tumor size, overdiagnosis, and mammography screening effectiveness. N Engl J Med. 2016 Oct 13;375(15):1438–1447. https://doi.org/10.1056/NEJMoa1600249
  • Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med. 1981 Jul 2;305(1):6–11.
  • Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med. 1985 Mar 14;312(11):665–673.
  • Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005 Dec 17;366(9503):2087–2106.
  • Kummerow KL, Du L, Penson DF, et al. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg. 2015 Jan;150(1):9–16.•• This study of considerable interest demonstrates the increase in unilateral and bilateral mastectomies performed in the United States in BCS-eligible patients.
  • Bouganim N, Tsvetkova E, Clemons M, et al. Evolution of sites of recurrence after early breast cancer over the last 20 years: implications for patient care and future research. Breast Cancer Res Treat. 2013 Jun;139(2):603–606.
  • Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol. 2005 Aug 20;23(24):5526–5533.• This study of interest shows the effect of patient-reported participation in the treatment decision process on the rate of mastectomy.
  • Moran MS, Schnitt SJ, Giuliano AE, et al. Society of surgical oncology-American society for radiation oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. J Clin Oncol. 2014 May 10;32(14):1507–1515.
  • Azu M, Abrahamse P, Katz SJ, et al. What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol. 2010 Feb;17(2):558–563.
  • Marinovich ML, Noguchi N, Morrow M, et al. Changes in reoperation after publication of consensus guidelines on margins for breast-conserving surgery: a systematic review and meta-analysis. JAMA Surgery. 2020 Oct 1;155(10):e203025. . https://doi.org/10.1001/jamasurg.2020.3025• This study of interest illustrates the impact of consensus guidelines on clinical practice, with variation in effect between the institution and population level
  • Morrow M, Abrahamse P, Hofer TP, et al. Trends in reoperation after initial lumpectomy for breast cancer: addressing overtreatment in surgical management. JAMA Oncol. 2017 Oct 1;3(10):1352–1357. https://doi.org/10.1001/jamaoncol.2017.0774
  • Morrow M, Strom EA, Bassett LW, et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin. 2002 Sep-Oct;52(5):277–300. https://doi.org/10.3322/canjclin.52.5.277
  • Korde LA, Somerfield MR, Carey LA, et al. Neoadjuvant chemotherapy, endocrine therapy, and targeted therapy for breast cancer: ASCO guideline. J Clin Oncol. 2021 May 1;39(13):1485–1505. https://doi.org/10.1200/JCO.20.03399
  • Golshan M, Loibl S, Wong SM, et al. Breast conservation after neoadjuvant chemotherapy for triple-negative breast cancer: surgical results from the BrighTNess randomized clinical trial. JAMA Surg. 2020 Mar 1;155(3):e195410.• This study of interest shows worldwide variations in patients’ choice of surgical intervention (BCT versus mastectomy) and extent of surgery (unilateral versus bilateral), among BCT-eligible women.
  • Ataseven B, Lederer B, Blohmer JU, et al. Impact of multifocal or multicentric disease on surgery and locoregional, distant and overall survival of 6,134 breast cancer patients treated with neoadjuvant chemotherapy. Ann Surg Oncol. 2015 Apr;22(4):1118–1127.
  • Rosenkranz KM, Ballman K, McCall L, et al. The feasibility of breast-conserving surgery for multiple ipsilateral breast cancer: an initial report from ACOSOG Z11102 (alliance) trial. Ann Surg Oncol. 2018 Oct;25(10):2858–2866.
  • Curigliano G, Burstein HJ, Winer EP, et al. De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol. 2017 Aug 1;28( 8):1700–1712.
  • Davey MG, Davey CM, Ryan EJ, et al. Combined breast conservation therapy versus mastectomy for BRCA mutation carriers - A systematic review and meta-analysis. Breast. 2021 Apr;56:26–34.
  • Tung NM, Boughey JC, Pierce LJ, et al. Management of hereditary breast cancer: American society of clinical oncology, American society for radiation oncology, and society of surgical oncology guideline. J Clin Oncol. 2020 Jun 20;38(18):2080–2106.
  • Arthur DW, Winter KA, Kuerer HM, et al. Effectiveness of breast-conserving surgery and 3-dimensional conformal partial breast reirradiation for recurrence of breast cancer in the ipsilateral breast: the NRG oncology/RTOG 1014 phase 2 clinical trial. JAMA Oncol. 2020 Jan 1;6(1):75–82.
  • Montagna G, Morrow M Contralateral prophylactic mastectomy in breast cancer: what to discuss with patients. Expert Rev Anticancer Ther. 2020 Mar;20(3):159–166.
  • Hawley ST, Li Y, An LC, et al. Improving breast cancer surgical treatment decision making: the iCanDecide randomized clinical trial. J Clin Oncol. 2018 Mar 1;36(7):659–666.
  • Manne SL, Smith BL, Frederick S, et al. B-Sure: a randomized pilot trial of an interactive web-based decision support aid versus usual care in average-risk breast cancer patients considering contralateral prophylactic mastectomy. Transl Behav Med. 2020 May 20;10(2):355–363.
  • Jagsi R, Hawley ST, Griffith KA, et al. Contralateral prophylactic mastectomy decisions in a population-based sample of patients with early-stage breast cancer. JAMA Surg. 2017 Mar 1;152(3):274–282.• This study of interest shows the effect of surgeon recommendation on patients’ decisions regarding CPM.
  • Fisher B, Montague E, Redmond C, et al. Comparison of radical mastectomy with alternative treatments for primary breast cancer. A first report of results from a prospective randomized clinical trial. Cancer. 1977 Jun;39(6 Suppl):2827–2839.
  • Howard DH, Soulos PR, Chagpar AB, et al. Contrary to conventional wisdom, physicians abandoned a breast cancer treatment after a trial concluded it was ineffective. Health Aff (Millwood). 2016 Jul 1;35(7):1309–1315.•• This study of significant interest demonstrates the uptake and practice changes in the United States following publication of the ACOSOG Z0011 trial results.
  • Poodt IGM, Spronk PER, Vugts G, et al. Trends on axillary surgery in nondistant metastatic breast cancer patients treated between 2011 and 2015: a Dutch population-based study in the ACOSOG-Z0011 and AMAROS era. Ann Surg. 2018 Dec;268(6):1084–1090.•• This study of significant interest illustrates the success in altering clinical practice following publication of the ACOSOG Z0011 and AMAROS trial results.
  • Morrow M, Van Zee KJ, Patil S, et al. Axillary dissection and nodal irradiation can be avoided for most node-positive Z0011-eligible breast cancers: a prospective validation study of 793 patients. Ann Surg. 2017 Sep;266(3):457–462.
  • Castelo M, Hu SY, Dossa F, et al. Comparing observation, axillary radiotherapy, and completion axillary lymph node dissection for management of axilla in breast cancer in patients with positive sentinel nodes: a systematic review. Ann Surg Oncol. 2020 Aug;27(8):2664–2676.
  • Kantor O, Means J, Grossmith S, et al. Optimizing axillary management in clinical T1-2N0 mastectomy patients with positive sentinel lymph nodes. Ann Surg Oncol. 2022 Feb;29(2):972–980.•• This study of interest shows the real-world results of deferring completion ALND at the time of initial mastectomy in AMAROS-eligible patients.
  • Warren LE, Miller CL, Horick N, et al. The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study. Int J Radiat Oncol Biol Phys. 2014 Mar 1;88(3):565–571.
  • Goyal A, Dodwell D POSNOC: a randomised trial looking at axillary treatment in women with one or two sentinel nodes with macrometastases. Clin Oncol (R Coll Radiol). 2015 Dec;27(12):692–695.
  • de Boniface J, Frisell J, Andersson Y, et al. Survival and axillary recurrence following sentinel node-positive breast cancer without completion axillary lymph node dissection: the randomized controlled SENOMAC trial. BMC Cancer. 2017 May 26;17(1):379.
  • Gentilini O, Veronesi U Abandoning sentinel lymph node biopsy in early breast cancer? A new trial in progress at the European Institute of Oncology of Milan (SOUND: sentinel node vs Observation after axillary UltraSouND). Breast. 2012 Oct;21(5):678–681.
  • Henke G, Knauer M, Ribi K, et al. Tailored axillary surgery with or without axillary lymph node dissection followed by radiotherapy in patients with clinically node-positive breast cancer (TAXIS): study protocol for a multicenter, randomized phase-III trial. Trials. 2018 Dec 4;19(1):667.
  • Reimer T, Stachs A, Nekljudova V, et al. Restricted axillary staging in clinically and sonographically node-negative early invasive breast cancer (c/iT1-2) in the context of breast conserving therapy: first results following commencement of the Intergroup-Sentinel-Mamma (INSEMA) Trial. Geburtshilfe Frauenheilkd. 2017 Feb;77(2):149–157.
  • van Roozendaal Lm, Vane MLG, van Dalen T, et al. Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08). BMC Cancer. 2017 Jul 1;17(1):459.
  • Simons JM, van Nijnatten TJA, van der Pol CC, et al. Diagnostic accuracy of different surgical procedures for axillary staging after neoadjuvant systemic therapy in node-positive breast cancer a systematic review and meta-analysis. Ann Surg. 2019 Mar;269(3):432–442.
  • Barrio AV, Montagna G, Mamtani A, et al. Nodal recurrence in patients with node-positive breast cancer treated with sentinel node biopsy alone after neoadjuvant chemotherapy-a rare event. JAMA Oncol. 2021 Dec 1;7(12)1851–1855.
  • Montagna G, Mamtani A, Knezevic A, et al. Selecting node-positive patients for axillary downstaging with neoadjuvant chemotherapy. Ann Surg Oncol. 2020 Oct;27(11):4515–4522.
  • Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013 Jul 1;31(19):2382–2387.
  • McKevitt E, Cheifetz R, DeVries K, et al. Sentinel node biopsy should not be routine in older patients with ER-positive HER2-negative breast cancer who are willing and able to take hormone therapy. Ann Surg Oncol. 2021 Oct;28(11):5950–5957.
  • Armani A, Douglas S, Kulkarni S, et al. Controversial areas in axillary staging: are we following the guidelines? Ann Surg Oncol. 2021 Oct;28(10):5580–5587.•• This study of significant interest highlights physician-associated variables that present as barriers in adopting new treatment guidelines.
  • Smith ME, Vitous CA, Hughes TM, et al. Barriers and facilitators to de-implementation of the choosing wisely(®) guidelines for low-value breast cancer surgery. Ann Surg Oncol. 2020 Aug;27(8):2653–2663.•• This study of significant interest highlights the approach and attitude of surgeons toward integrating de-escalation of care guidelines into their practice.
  • Wang T, Mott N, Miller J, et al. Patient perspectives on treatment options for older women with hormone receptor-positive breast cancer: a qualitative study. JAMA Network Open. 2020 Sep 1;3(9):e2017129.• This study of interest reports on patients’ perspectives regarding Choosing Wisely recommendations.
  • Kalinsky K, Barlow WE, Gralow JR, et al. 21-Gene assay to inform chemotherapy benefit in node-positive breast cancer. N Engl J Med. 2021;385(25):2336–2347.
  • Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011 Nov 12;378(9804):1707–1716.
  • Murray Brunt A, Haviland JS, Wheatley DA, et al. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial. Lancet. 2020 May 23;395(10237):1613–1626.
  • Wang SL, Fang H, Hu C, et al. Hypofractionated versus conventional fractionated radiotherapy after breast-conserving surgery in the modern treatment era: a multicenter, randomized controlled trial from China. J Clin Oncol. 2020 Nov 1;38(31):3604–3614.
  • Bekelman JE, Sylwestrzak G, Barron J, et al. Uptake and costs of hypofractionated vs conventional whole breast irradiation after breast conserving surgery in the United States, 2008-2013. Jama. 2014 Dec 17;312(23):2542–2550.• This study of interest highlights the limited adoption of hypofractioned WBI in the United States.
  • Kang MM, Hasan Y, Waller J, et al. Has hypofractionated whole-breast radiation therapy become the standard of care in the United States? An updated report from national cancer database. Clin Breast Cancer. 2022 Jan;22(1):e8–e20.
  • Ashworth A, Kong W, Whelan T, et al. A population-based study of the fractionation of postlumpectomy breast radiation therapy. Int J Radiat Oncol Biol Phys. 2013 May 1;86(1):51–57.
  • Hickey BE, Lehman M Partial breast irradiation versus whole breast radiotherapy for early breast cancer. Cochrane Database Syst Rev. 2021 Aug 30;8(8): Cd007077.
  • Gregucci F, Fozza A, Falivene S, et al. Present clinical practice of breast cancer radiotherapy in Italy: a nationwide survey by the Italian Society of Radiotherapy and Clinical Oncology (AIRO) Breast Group. Radiol Med. 2020 Jul;125(7):674–682.
  • Chu QD, Zhou M, Medeiros KL, et al. Impact of CALGB 9343 trial and sociodemographic variation on patterns of adjuvant radiation therapy practice for elderly women (≥70 years) with stage I, estrogen receptor-positive breast cancer: analysis of the national cancer data base. Anticancer Res. 2017 Oct;37(10):5585–5594.• This study of interest illustrates how the publication of the CALGB 9343 results has had minimal impact on reducing radiotherapy utilization in elderly women.
  • Shumway DA, Griffith KA, Sabel MS, et al. Surgeon and radiation oncologist views on omission of adjuvant radiotherapy for older women with early-stage breast cancer. Ann Surg Oncol. 2017 Nov;24(12):3518–3526.• This study of interest reports misconceptions that physicians have regarding the benefit of radiotherapy in patients meeting CALGB 9343 eligibility criteria.
  • Montagna G, Morrow M Breast-conserving surgery without radiation therapy for invasive cancer. Clin Breast Cancer. 2021 Apr;21(2):112–119.
  • Breast International Group, International Breast Cancer Study Group. EXamining personalised radiation therapy for low-risk Early Breast Cancer (EXPERT) 2021 [Accessed January 3, 2022]. Available from: https://clinicaltrials.gov/ct2/show/NCT02889874
  • National Comprehensive Cancer Network (NCCN). NCCN Guidelines for Treatment of Cancer by Type, Version 5 2020 [Accessed January 3, 2022]. Available from: https://www.nccn.org/guidelines/recently-published-guidelines
  • Vaz-Luis I, O’Neill A, Sepucha K, et al. Survival benefit needed to undergo chemotherapy: patient and physician preferences. Cancer. 2017 Aug 1;123(15):2821–2828.•• This study of significant interest demonstrates the differing thresholds for which patients would be willing to undergo chemotherapy for incremental improvements in survival.
  • Slevin ML, Stubbs L, Plant HJ, et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public. Bmj. 1990 Jun 2;300(6737):1458–1460.
  • Sparano JA, Gray RJ, Makower DF, et al. Adjuvant chemotherapy guided by a 21-Gene expression assay in breast cancer. N Engl J Med. 2018 Jul 12;379(2):111–121.
  • Sparano JA, Gray RJ, Ravdin PM, et al. Clinical and genomic risk to guide the use of adjuvant therapy for breast cancer. N Engl J Med. 2019 Jun 20;380(25):2395–2405.
  • Carlson JJ, Roth JA The impact of the Oncotype Dx breast cancer assay in clinical practice: a systematic review and meta-analysis. Breast Cancer Res Treat. 2013 Aug;141(1):13–22.• This study of interest demonstrates the impact of Oncotype DX in altering chemotherapy recommendations.
  • Dieci MV, Guarneri V, Zustovich F, et al. Impact of 21-Gene breast cancer assay on treatment decision for patients with T1-T3, N0-N1, estrogen receptor-positive/human epidermal growth receptor 2-negative breast cancer: final results of the prospective multicenter ROXANE study. Oncologist. 2019 Nov;24(11):1424–1431.
  • Tolaney SM, Guo H, Pernas S, et al. Seven-Year follow-up analysis of adjuvant paclitaxel and trastuzumab trial for node-negative, human epidermal growth factor receptor 2-positive breast cancer. J Clin Oncol. 2019 Aug 1;37(22):1868–1875.
  • Mougalian SS, Soulos PR, Killelea BK, et al. Use of neoadjuvant chemotherapy for patients with stage I to III breast cancer in the United States. Cancer. 2015 Aug 1;121(15):2544–2552.
  • Masuda N, Lee SJ, Ohtani S, et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017 Jun 1;376(22):2147–2159.
  • von Minckwitz G, Huang CS, Mano MS, et al. Trastuzumab emtansine for residual invasive HER2-positive breast cancer. N Engl J Med. 2019 Feb 14;380(7):617–628.
  • Narod SA, Iqbal J, Giannakeas V, et al. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015 Oct;1(7):888–896.
  • Julian TB, Land SR, Fourchotte V, et al. Is sentinel node biopsy necessary in conservatively treated DCIS? Ann Surg Oncol. 2007 Aug;14(8):2202–2208.
  • Hage Chehade H E, Headon H, Wazir U, et al. Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis. Am J Surg. 2017 Jan;213(1):171–180.
  • Worni M, Akushevich I, Greenup R, et al. Trends in treatment patterns and outcomes for ductal carcinoma in situ. J Natl Cancer Inst. 2015 Dec;107(12):djv263.
  • Stuart KE, Houssami N, Taylor R, et al. Long-term outcomes of ductal carcinoma in situ of the breast: a systematic review, meta-analysis and meta-regression analysis. BMC Cancer. 2015 Nov 10;15:890.
  • Correa C, McGale P, Taylor C, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010(41):162–177.
  • Solin LJ, Gray R, Hughes LL, et al. Surgical excision without radiation for ductal carcinoma in situ of the breast: 12-year results from the ECOG-ACRIN E5194 study. J Clin Oncol. 2015 Nov 20;33(33):3938–3944.
  • McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015 Mar 1;33(7):709–715.
  • Hawley ST, Janz NK, Griffith KA, et al. Recurrence risk perception and quality of life following treatment of breast cancer. Breast Cancer Res Treat. 2017 Feb;161(3):557–565.•• This study of significant interest illustrates how a significant proportion of women with DCIS overestimate their risk of systemic recurrence.
  • Subhedar P, Olcese C, Patil S, et al. Decreasing recurrence rates for ductal carcinoma in situ: analysis of 2996 women treated with breast-conserving surgery over 30 years. Ann Surg Oncol. 2015 Oct;22(10):3273–3281.
  • Katz SJ, Lantz PM, Janz NK, et al. Patterns and correlates of local therapy for women with ductal carcinoma-in-situ. J Clin Oncol. 2005 May 1;23(13):3001–3007.
  • Rudloff U, Jacks LM, Goldberg JI, et al. Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol. 2010 Aug 10;28(23):3762–3769.
  • Solin LJ, Gray R, Baehner FL, et al. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst. 2013 May 15;105(10):701–710.
  • Rakovitch E, Parpia S, Koch A, et al. DUCHESS: an evaluation of the ductal carcinoma in situ score for decisions on radiotherapy in patients with low/intermediate-risk DCIS. Breast Cancer Res Treat. 2021 Jul;188(1):133–139.
  • Allred DC, Anderson SJ, Paik S, et al. Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24. J Clin Oncol. 2012 Apr 20;30(12):1268–1273.
  • Cuzick J, Sestak I, Pinder SE, et al. Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol. 2011 Jan;12(1):21–29.
  • Zujewski JA, Harlan LC, Morrell DM, et al. Ductal carcinoma in situ: trends in treatment over time in the US. Breast Cancer Res Treat. 2011 May;127(1):251–257.
  • Hwang ES, Solin L De-Escalation of locoregional therapy in low-risk disease for DCIS and early-stage invasive cancer. J Clin Oncol. 2020 Jul 10;38(20):2230–2239.
  • Pilewskie M, Stempel M, Rosenfeld H, et al. Do LORIS trial eligibility criteria identify a ductal carcinoma in situ patient population at low risk of upgrade to invasive carcinoma? Ann Surg Oncol. 2016 Oct;23(11):3487–3493.
  • Partridge A, Adloff K, Blood E, et al. Risk perceptions and psychosocial outcomes of women with ductal carcinoma in situ: longitudinal results from a cohort study. J Natl Cancer Inst. 2008 Feb 20;100(4):243–251.
  • Pilewskie M, Olcese C, Patil S, et al. Women with Low-Risk DCIS Eligible for the LORIS Trial After Complete Surgical Excision: how Low Is Their Risk After Standard Therapy? Ann Surg Oncol. 2016 Dec;23(13):4253–4261.
  • Davis DA, Thomson MA, Oxman AD, et al. Changing physician performance. A systematic review of the effect of continuing medical education strategies. Jama. 1995 Sep 6;274(9):700–705.•• This study of significant interest demonstrates the improved success rate in affecting change in clinical practice with targeted interventions.
  • van Hoeve J, de Munck L, Otter R, et al. Quality improvement by implementing an integrated oncological care pathway for breast cancer patients. Breast. 2014 Aug;23(4):364–370.
  • Haward R, Amir Z, Borrill C, et al. Breast cancer teams: the impact of constitution, new cancer workload, and methods of operation on their effectiveness. Br J Cancer. 2003 Jul 7;89(1):15–22.
  • Ehdaie B, Assel M, Benfante N, et al. A systematic approach to discussing active surveillance with patients with low-risk prostate cancer. Eur Urol. 2017 Jun;71(6):866–871.
  • King TA, Morrow M Surgical issues in patients with breast cancer receiving neoadjuvant chemotherapy. Nat Rev Clin Oncol. 2015 Jun;12(6):335–343.
  • Veronesi U, Stafyla V, Luini A, et al. Breast cancer: from “maximum tolerable” to “minimum effective” treatment. Front Oncol. 2012;2:125.

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