Xinguang Wang,Zhaoqing Fan

Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing),Breast Center,Peking University Cancer Hospital＆Institute,Beijing 100142,China

China is facing growing number of cancer cases and deaths,as well as growing crude incidence and mortality of cancer.Breast cancer is the most common cancer type in females in China and the incidence rate for breast cancer in Chinese females has increased during the last two decades.However,breast cancer prognosis in China is poorer than that in developed countries.Population aging may at least partially explain the transition of cancer profiles we have seen in recent years.Breast cancer screening technologies and public healthcare strategies targeting the high-risk population are being developed to reduce the cancer burden in China.

In order to provide optimal treatment approaches based on available evidence,the National Health Commission of the People’s Republic of China developed therapy algorithms for primary and advanced breast cancer.It has been four years since the last update ofthe Chinese guidelines for diagnosis and treatment of breast cancer.In 2022,a working group was formed to update the guidelines(1).China is the largest developing country in the world with major differences in social economic status among regions.Although international guidelines such as the National Comprehensive Cancer Network (NCCN)guidelines on breast cancer have been widely accepted by Chinese breast surgeons,members of the working group unanimously agreed that it is almost impossible to provide a “one size fit all” cancer screening and treatment plan and a set of guidelines specially developed for Chinese breast cancer patients would provide reproducible and evidencebased treatment algorithms and may be helpful for a broad treatment landscape.

Multidisciplinary management of breast cancer patients is now standard of care.Ideally,breast cancer treatment should be tailored to each individual patient depending on the individual risk profile.Performance status,comorbidities,patient preference,prior therapies and other factors such as social economic status should be taken into account for the actual treatment choice.Pivotal studies have been published in the last few years,as well as the availability of new drugs that have transformed the landscape of the treatment of early and advanced breast carcinoma.Based on the available evidence,clinicians nowadays often need to make decisions regarding escalation or de-escalation of treatment.For instance,adjuvant trastuzumab monotherapy might be sufficient for human epidermal growth factor receptor 2 (HER-2)positive early breast cancer patients with pathological complete response (pCR) and negative lymph nodes before and after neoadjuvant chemotherapy,while dual HER-2 blockade with trastuzumab plus pertuzumab is usually recommended for patients with lymph node involvement.Adjuvant trastuzumab emtansine (T-DM1) is recommended for patients who have residual invasive diseases in the breast or lymph nodes following optimal neoadjuvant systemic therapy.Other good examples of tailored treatment would include recent developments in CDK4/6 inhibitors,immune checkpoint inhibitors[programmed cell death protein-1 (PD-1) and its ligand PD-L1] and PARP inhibitors.

Modern precise diagnostic and tumor localization methods as well as increasingly effective systemic treatment have led to the revolutionary change of traditional surgical therapy for breast cancer.Breast conserving surgery in combination with primary systemic treatments and the application of oncoplastic principles are now generally accepted.Oncoplastic breast surgery has become an essential part of the multidisciplinary treatment of breast cancer in many regions in China.The use of ADM/TiLoop products may allow reconstruction to be completed in a single procedure instead of two procedures with initial use of a tissue expander.However,patients need to be informed about and the advantages and disadvantages of the new technique.Axillary staging also has become ever less radical in recent years.In case of cN0 patients (both clinically and sonographically axillary lymph negative)before and after neoadjuvant chemotherapy (NACT),sentinel lymph node biopsy (SLNB) is the axillary staging method of choice and should be performed after NACT.Clinically suspicious lymph node before NACT should be verified by biopsy and it is recommended to clip the biopsy-proven positive lymph node in experienced institutions and targeted axillary dissection is preferred if the clipped node converted to clinically node-negative after NACT.

Radiation therapy remains a fundamental part of multidisciplinary breast cancer treatment.Regional lymph node irradiation after neoadjuvant therapy is controversial.Prospective clinical studies are underway yet currently data have not yet been published.Instead of the conventional fractionation,hypofractionated whole breast irradiation(WBI),which is less time-consuming and more cost effective,has been applied to many patients after breast conserving surgery.Data of further long-term efficacy and adverse effect of hypofractionation radiotherapy are necessary.

How to optimize the usage of available biomarkers in early breast cancer patients is gaining attention.Ki-67 is one of the main topics of discussion in the field of breast pathology.It is an established pathological prognostic marker for early breast cancer patients.However,its role is debated due to its inconsistent clinical assessment and variability.As a result,the International Ki-67 in Breast Cancer Working Group (IKWG) recently concluded that clinical utility of Ki-67 is evident only for prognosis estimation in anatomically favorable ER-positive and HER-2 negative patients to identify those who do not need adjuvant chemotherapy.The use of genomic assays to avoid or recommend chemotherapy and to predict response to neoadjuvant therapy is still under discussion.

Today,we are on the edge of a series of major treatment breakthroughs.New drugs such as T-DXd and the recognition of HER2-low breast cancer as a new treatment category will greatly change the treatment algorithms of early breast cancer in the near future and benefit the patients.

Acknowledgements

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Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.