[Evidence-based medicine advances in de-escalation strategies for local surgical treatment of breast cancer].

With the continuous optimization of systemic treatment regimens and the advancement of imaging assessment technologies, the overall survival rate of early-stage breast cancer has been steadily improving, providing an evidence-based basis for exploring de-escalation of local surgical treatment. This article systematically reviews five pathways for de-escalation of local surgical treatment in breast cancer and their key clinical evidence: selective exemption from breast surgery after neoadjuvant therapy by verifying pathologic complete response through imaging combined with vacuum-assisted biopsy (NRG-BR005, MICRA, MD Anderson Exceptional Responders trials, etc.); active surveillance replacing immediate surgery for low-risk ductal carcinoma in situ (COMET, LORIS, LORD, etc.); percutaneous ablation replacing partial breast-conserving surgery (ICE3, PO-RAFAELO, etc.); exemption from sentinel lymph node biopsy for patients with clinically negative lymph nodes and negative axillary ultrasound (INSEMA, SOUND, etc.); and reducing the false-negative rate (FNR) by using sentinel combined with targeted axillary dissection to avoid axillary lymph node dissection in initially node-positive patients who convert to clinically node-negative after neoadjuvant therapy (ACOSOG Z1071, SENTINA, SN FNAC, etc.). The clinical translation of the above strategies requires precise risk stratification, standardized pathological assessment, closed-loop long-term follow-up, and fully informed decision-making. Its core lies in establishing a comprehensive management plan based on rigorous screening and evidence-driven approaches, grounded in verifiable complete remission or low risk.