Editor’s Note : Recently, the 17th Shanghai Breast Cancer Professional Symposium, held in conjunction with the Annual Meeting of the Breast Cancer Committee of the Shanghai Anti-Cancer Association and the 2026 Breast Cancer Guideline “Red Book” Update Meeting, took place in Shanghai. During the meeting, the 2026 Edition of the Essentials of the Breast Cancer Diagnosis and Treatment Guidelines and Specifications—jointly issued by the Chinese Anti-Cancer Association Breast Cancer Committee (CBCS) and the Breast Oncology Group of the Chinese Society of Clinical Oncology (CSOBO)—was officially released (hereinafter referred to as the new Red Book).On the occasion of the release of the new Red Book, Oncology Frontier invited Professor Benlong Yang from Fudan University Shanghai Cancer Center to provide an in-depth interpretation of two key updates in the surgical section: surgical management of the primary breast lesion in stage IV breast cancer, and standards for prophylactic total mastectomy. The goal is to offer clearer and more prudent guidance for clinical practice.
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Oncology Frontier: The 2026 Edition of the CBCS & CSOBO Breast Cancer Diagnosis and Treatment Guidelines and Specifications (the new Red Book) has now been officially released. A new section has been added to the surgical chapter addressing principles for surgical treatment of the primary breast lesion in stage IV breast cancer. Could you introduce the key points of this update?
Professor Benlong Yang: First, I would like to thank Oncology Frontier for its attention to the guideline update process. The issue of managing the primary tumor in stage IV breast cancer has been repeatedly raised by grassroots clinicians during guideline lecture tours over the years, with many calling for its inclusion in the guidelines. Indeed, with continuous advances in systemic therapies for breast cancer, an increasing number of stage IV patients can now achieve long-term disease stability under effective systemic treatment. At this stage, some patients begin to request local interventions.
A review of the literature reveals inconsistency in the evidence base. Most retrospective studies suggest that resection of the primary tumor in stage IV breast cancer may confer a survival benefit. However, several prospective clinical studies—including the TBCRC 013 study and a randomized controlled trial conducted by the Tata Memorial CentreA in India—have indicated that surgery does not improve survival in patients with stage IV disease.
Against this background, the current guideline update focused on two main objectives. First, the topic has been formally incorporated into the guidelines to provide principle-based guidance for breast surgeons in China. It must be emphasized that for patients with stage IV breast cancer, local treatment is purely palliative in nature, intended to relieve symptoms and improve quality of life, rather than to achieve cure. Clarifying this principle is critically important.
Second, we hope the guidelines will help frontline clinicians identify which patients may potentially benefit from surgery. Based on a comprehensive literature review, we extracted characteristics of subgroups that may derive survival benefit and organized a voting discussion among leading domestic surgical experts at the SIBCS meeting. Ultimately, we reached consensus that patients considered suitable for surgical intervention should meet all of the following criteria:
- Low tumor burden: distant metastases are oligometastatic (few metastatic sites, typically ≤3) or confined to bone and/or soft tissue;
- Good response to systemic therapy: this is the most critical factor—patients should be highly sensitive to systemic treatment, with progression-free survival (PFS) ideally exceeding the median PFS of the given regimen;
- Favorable life expectancy: an expected survival of more than two years;
- Patient preference and multidisciplinary consensus: the patient has a strong desire for surgery, and the treatment plan has been approved through thorough multidisciplinary team (MDT) discussion.
Therefore, although this content has been newly added to the guidelines, our intention is very clear: it is not to encourage surgery for all patients with stage IV breast cancer, but rather to remind clinicians to proceed with caution and to always place patient benefit at the center of decision-making.
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Oncology Frontier: As a surgeon, what is your perspective on prophylactic mastectomy? Please share your views in light of the newly added content on “prophylactic total mastectomy” in the new Red Book.
Professor Benlong Yang: This topic is actually even more controversial. Several years ago, American actress Angelina Jolie publicly shared her experience of undergoing prophylactic bilateral mastectomy, which triggered the so-called “Jolie effect” and widespread global discussion. Some experts in the field have pointed out that the survival benefit of such procedures is not clearly established. If prophylactic surgery is overly encouraged, it may not only lead to unnecessary consumption of medical resources but also expose patients to unpredictable harm. Even with breast reconstruction, risks such as sensory nerve loss and surgical complications remain and may have long-term impacts on quality of life.
For this reason, the new Red Book sets much stricter requirements for prophylactic mastectomy. We categorize prophylactic surgery into two types: one is prophylactic removal of the contralateral healthy breast in patients who already have breast cancer in one breast; the other is prophylactic surgery in otherwise healthy women. Regardless of the category, two key conditions must be clearly met. First, the patient must carry a hereditary susceptibility gene mutation, such as pathogenic BRCA1/2 mutations. Second, there must be clear and extensive high-risk lesions—such as lobular carcinoma in situ (LCIS) or widespread severe ductal atypical hyperplasia—combined with a strong patient इच्छा for surgery. This approach has also been reflected in previous NCCN guidelines.
In fact, the new Red Book does not relax surgical indications; rather, it tightens them further. We place particular emphasis on special preoperative requirements: patients must sign a dedicated informed consent form, fully understand the risks and benefits of surgery, and demonstrate a high level of acceptance of the decision. In addition, genetic testing should ideally be a mandatory component of surgical decision-making. If a patient has a strong family history but refuses genetic testing, prophylactic mastectomy is not recommended.
Professor Benlong Yang
Department of Breast Surgery Fudan University Shanghai Cancer Center
