Breast conservation therapy has largely replaced mastectomy as the surgical treatment of choice for early-stage breast cancer. As the sentinel lymph node mapping procedure, rather than routine axillary node dissection, becomes the standard of care, the next challenge is how to treat the primary tumor without surgery. Minimally invasive ablation of the primary tumor is possible with a variety of approaches; the goal is to either excise the tumor percutaneously or cool it (with cryotherapy) or heat it (with radiofrequency ablation (RFA), focused ultrasound, or laser interstitial therapy) sufficiently to cause complete cell death. These developing technologies may provide treatment options that are psychologically and cosmetically more acceptable to the patient than traditional therapies, but they need further investigation to prove that they are oncologically sound. This new frontier of surgery without scalpels will require surgeons to develop radiologic expertise and to acquire a basic understanding of molecular biology.

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Recent clinical trials of adjuvant therapy for early stage breast cancer support two general observations. First, overall survival is not impacted by the extent of surgery. Low rates of axillary relapse in patients treated with total mastectomy alone combined with the availability of systemic therapy as a substitute for surgical control of the axilla mean that patients can often be spared the morbidity of axillary node dissection. In problematic cases, newer diagnostic approaches, such as sentinel node biopsy, can help in making appropriate treatment decisions. Second, systemic therapy can reduce the clinical manifestations of disease. The incorporation of more sophisticated approaches to predicting outcomes, to varying timing and dose of treatment, and to developing new modalities of treatment, including immunotherapy, will contribute to a general strategy aimed at reducing the tumor to a harmless parasite. These observations support a paradigm shift in our definition of 'adjuvant'. Rather than referring to the use of systemic therapy after the patient's known disease has been surgically removed, adjuvant therapy would be re-defined to refer to local therapy used to eradicate any residual tumor remaining after systemic therapy has been completed.

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