Time to stop operating on breast cancer patients with pathological complete response?

Surgery is an obligatory component of treatment for early breast cancer. The last 20 years developments in systemic neoadjuvant therapy have progressively increased pathological complete response (pCR). Pathological complete response is associated with excellent prognosis especially for hormone receptor negative cancers. Therapeutic advances and recognition of the importance of pathological subtype in predicting pCR facilitate identification of subgroups with very high pCR rates. Treatment of HER2 positive hormone receptor negative cancers with combination chemotherapy and multiple targeted anti-HER2 agents results in consistently high pCR rates of 60-83%. Routine surgery in this setting where most patients have no potential to benefit is of questionable value and the option of omitting surgery in these patients should now be explored in a randomized trial. For HER2 positive disease not achieving pCR after neoadjuvant treatment the outcomes are poor. Trials are underway to determine if outcomes for these patients can be improved with alternative targeted therapy.