Summary of recommendations | How can practice change? | |
---|---|---|
| Avoid ALND for patients undergoing upfront surgery who had a positive SLNB (cT1-2). | - Decreased unnecessary ALND and surgery-related morbidity (eg, lymphedema). - Locoregional control through radiotherapy and adjuvant systemic therapy. |
Consider ALND for patients who had positive SLNB after NAT. | - More appropriate axillary staging and prognostic information about the disease. - Reduction of locoregional and distant recurrences. | |
| Avoid the unrestricted indication of bilateral mastectomy. | - Reduction of morbidity and financial costs related to bilateral mastectomy. - Prioritize patients with pathogenic mutations, especially if < 60 years of age. |
Consider “no ink on tumor” as being indicative of adequate surgical margins. | - Decreased re-operations and mastectomies by close margins. | |
| Avoid the evaluation of flap thickness using imaging methods. | - Avoid unnecessary RT in women with T1-2 N0 tumors submitted to mastectomy. |
| Add platinum agents to NAT regimens (irrespective of BRCA mutations). | - Increase in pCR rate and event-free survival. - Slight increase in toxicity. |
Add immune checkpoint inhibitors to NAT (irrespective of PD-L1 expression). | - Use of pembrolizumab as indicated in the KEYNOTE-522 study. - Increase in pCR rate and event-free survival. - Slight increase in toxicity and immune-mediated events. | |
Consider adjuvant capecitabine to patients undergoing NAT with residual disease. | - Increased disease-free survival and overall survival. - Slight increase in toxicity. |