Breast Cancer Surgery: Past, Present and Future—A Narrative Review

Breast cancer surgery has evolved from radical procedures to increasingly individualized and less invasive approaches. This narrative review contextualizes this evolution, synthesizes current evidence supporting surgical de-escalation, and examines emerging strategies that may further reduce the need for surgery. The manuscript is based on a structured appraisal of PubMed/MEDLINE literature and major international guidelines, prioritizing randomized trials, prospective studies, and consensus statements. Contemporary practice is characterized by progressive reduction in both breast and axillary surgery, enabled by advances in tumour biology, neoadjuvant systemic therapy, sentinel node strategies, and oncoplastic techniques. Emerging approaches—including selective omission of axillary surgery, targeted axillary dissection, and investigational strategies aiming at omission of breast surgery in exceptional responders—highlight a shift toward response-adapted and biology-driven care. While technological innovations such as robotic surgery and intraoperative radiotherapy may influence surgical practice, their role in true de-escalation remains limited or context-dependent. Overall, the field is moving toward minimizing surgical burden without compromising oncological safety, with future progress likely driven by improved patient selection, imaging, and integration of systemic therapy response.