Editor’s Note: With the expanding role of neoadjuvant therapy in breast cancer, pathologic complete response (pCR) has become an important indicator for evaluating treatment efficacy. Whether patients who achieve pCR can safely omit surgery, axillary lymph node dissection, or regional radiotherapy has emerged as a key question in current clinical research.
At the 11th Qingdao Breast Disease Conference, Oncology Frontier invited Professor Xin Wang from the National Cancer Center / Cancer Hospital, Chinese Academy of Medical Sciences, to share insights on this topic. Drawing upon multiple lines of clinical evidence, Professor Wang discussed the potential and challenges of omitting local therapy in pCR patients and provided perspectives on future clinical translation and research directions.
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Oncology Frontier: You participated in a debate at this year’s conference on whether patients who achieve pCR after neoadjuvant therapy can be exempted from surgery, axillary lymph node dissection, or regional radiotherapy. Could you share your viewpoint and the main supporting evidence?
Professor Xin Wang: It was an honor to participate in the 11th Qingdao Breast Disease Conference and the 9th “Langya Forum.” This year, the forum hosted several thematic debates, one of which focused on whether patients who achieve pCR after neoadjuvant therapy can be exempted from local treatments such as surgery, axillary lymph node dissection, and regional radiotherapy.
This topic has been one of the most debated issues in clinical breast oncology in recent years. During the session, I had the pleasure of engaging in a discussion with Professor Wei Wu from Sun Yat-sen Memorial Hospital. I argued that for patients achieving pCR after neoadjuvant therapy, omitting local treatment—including surgery, axillary dissection, and radiotherapy—may be feasible under specific circumstances. My views are supported by the following evidence:
1.On Exempting Surgery: In triple-negative and HER2-positive breast cancers, a significant proportion of patients achieve pCR following neoadjuvant therapy. Avoiding surgery in these patients could reduce operative trauma, preserve breast contour, and enhance quality of life. During my fellowship at MD Anderson Cancer Center, Professor Henry M. Kuerer proposed that for patients whose imaging suggests pCR after neoadjuvant therapy, multiple core biopsies could be used to assess for residual disease. If no residual tumor is detected, whole-breast radiotherapy might replace mastectomy.
In 2022, Kuerer’s team published results in The Lancet Oncology: among patients with residual imaging lesions <2 cm and biopsy-confirmed non-invasive disease, whole-breast radiotherapy was used instead of surgery. After a median follow-up of 26.4 months, none of the 31 patients with confirmed pCR experienced ipsilateral breast recurrence or other relapse events. In 2025, the team reported updated results in JAMA Oncology, showing 0% recurrence and 100% survival among 50 patients with biopsy-confirmed pCR at a median follow-up of 55.4 months. These findings provide hope for surgery omission, though further multicenter validation is needed.
2.On Exempting Axillary Lymph Node Dissection: This strategy is gradually entering clinical practice. Current guidelines allow patients who are clinically node-negative after neoadjuvant therapy and in whom ≥3 sentinel nodes are successfully identified via dual tracer or clip marking to undergo sentinel lymph node biopsy (SLNB) instead of full axillary dissection. The false-negative rate of SLNB has fallen below 10%, and long-term data support this approach.
3. On Exempting Radiotherapy: For patients achieving pCR after neoadjuvant therapy, omitting radiotherapy is also being explored. The NSABP B-51 trial showed that patients whose axillary nodes became negative after neoadjuvant chemotherapy had low recurrence rates, and regional nodal irradiation did not confer a statistically significant benefit within 5 years. Ongoing trials such as HERO (NRG-BR008) are investigating even more ambitious de-escalation strategies, potentially omitting both surgery and radiotherapy.
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Oncology Frontier: Although numerous clinical trials are exploring this concept, omitting surgery and related interventions remains highly exploratory. From a breast surgeon’s perspective, what barriers must be overcome before such strategies can be translated from research into routine practice? How do you envision the future of this approach?
Professor Xin Wang: The idea of omitting surgery for patients achieving pCR was first proposed around 2019, when researchers began questioning whether patients confirmed as pCR by imaging or biopsy could safely forego surgery. However, at that year’s ESMO Congress, many experts expressed skepticism, arguing that core needle biopsy remains invasive and carries a false-negative risk, which could increase recurrence.
In China, Professor Jiong Wu from Fudan University Cancer Hospital has long advocated for the philosophy of simplifying surgery, but at present, surgery remains irreplaceable in breast oncology.
Currently, three main challenges remain:
- Variability in response by molecular subtype: Triple-negative and HER2-positive cancers achieve pCR more frequently and are the main focus of ongoing studies. In contrast, HR-positive/HER2-negative cancers—which make up around 70% of cases—have much lower pCR rates, making omission more difficult.
- Accurate assessment of pCR: Even when imaging or clinical evaluation suggests complete response, core biopsy accuracy is about 80–90%, leaving a false-negative risk. Advances in imaging and molecular assessment are needed to improve detection accuracy.
- Defining radiotherapy parameters: When radiotherapy replaces surgery, optimal dose and target areas remain uncertain. While axillary dissection can be replaced with SLNB plus radiotherapy, full omission of radiotherapy remains a major challenge.
Looking forward, surgery will remain essential but selective omission will become possible. The key is determining whether systemic therapy has truly achieved pCR with no residual disease, while optimizing radiotherapy to ensure equivalent local control. Through prospective clinical trials and evidence accumulation, clinicians can gradually integrate these strategies into routine practice.
Professor Xin Wang
National Cancer Center /Chinese Academy of Medical Sciences Cancer Hospital
