State of the Union: Breast Care in 2025

An interview with Roshni Rao, MD, Chief of the Division of Breast Surgery.

For more background, see our previous State of the Union with Dr. Rao.

Surgical Advances and Shifting Standards

What’s the single most meaningful change in breast care over the last year?

Probably the biggest one from a surgical perspective is the SOUND trial. That study looked at patients with small cancers. Normally, we would do a lumpectomy and then a sentinel node biopsy. But in this trial, they skipped the sentinel node and found just as good survival and recurrence outcomes.

So, for select patients, we’re no longer removing any lymph nodes. We’ve gone from removing all the lymph nodes, to a few, to now sometimes none at all.

Which patients qualify for skipping lymph node removal?

For us, it’s tumors less than two centimeters. The patient needs to be at least 60 years old, estrogen and progesterone receptor-positive, HER2-negative, and they need to have had an axillary ultrasound. If the axillary ultrasound is negative, we don’t need to do a sentinel node biopsy.

It’s a big change. Sentinel node biopsy isn’t terribly high-risk, but it does mean another incision, sometimes pain, and a small risk of lymphedema. With genomic analysis and other tools, we don’t rely on lymph node removal to guide chemotherapy decisions anymore. And radiation plus medication covers any microscopic disease that might be there.

Screening, Imaging, and Systemic Therapies

Are there updates in screening or imaging that patients should know about?

Yes. We’ve started offering contrast-enhanced mammography. Traditionally, it was mammogram, ultrasound, or MRI. This new approach uses contrast to give radiologists a better view and can pick up more cancers.

It’s especially helpful for women with dense breast tissue, and for those who fall into that middle risk group, higher than average (say, 17 percent), but not quite high enough for MRI. It’s not yet fully covered by insurance, and it requires nursing staff for the contrast, but we’ve developed a way to provide it without additional cost to patients.

What’s the latest with the I-SPY trials?

I-SPY continues to adapt. Patients are given treatments matched to their tumor’s biology, then monitored with MRI and biopsies. If they have a strong response, they go straight to surgery. If not, they escalate to a more aggressive regimen.

It’s disruptive for our OR schedules–sometimes we have to postpone surgery because a patient needs more chemo–but it’s great for patients. You get to start with the least toxic treatment and only escalate if necessary. Some recent findings are:

Timing after chemo – Our resident Julie Van Hassel analyzed 1,800 I-SPY patients and found that surgery can safely wait up to nine weeks after the last chemo dose. Timing didn’t matter for patients with a complete response.

And second, invasive lobular cancers – Traditionally, we thought these didn’t respond well to neoadjuvant treatment. But using genomic analysis (MammaPrint), we found 40 percent of invasive lobular cancers could be downstaged, much higher than we thought possible.

What about surgical strategy; how do you decide between lumpectomy vs mastectomy?

If the MRI shows a great response to treatment and the patient wants a lumpectomy, it’s safe to do so. And a “great response” means the tumor essentially melts away, and we can’t see anything on MRI.

For mastectomy patients, nipple-sparing works best if the nipple is in a good position without much drooping. Skin-sparing is an option for most patients unless they have very aggressive cancers with skin involvement.

We’re still using targeted axillary dissections with clips to minimize node removal. And for lymphedema, axillary reverse mapping with our plastic surgeons helps preserve lymphatics when we need to remove more nodes.

What should patients know about radiation today?

We’ve stopped offering intraoperative radiation therapy (IORT). But we still recommend radiation after lumpectomy, and most mastectomy patients can avoid it.

Partial breast radiation is an option for small, node-negative, hormone receptor–positive tumors in older patients. Patients are often scared of radiation, but modern techniques are precise. Damage to the heart and lungs is rare, treatments are quick, and side effects are usually limited to a sunburn-like reaction and some fatigue.

Any systemic therapies that are changing outcomes?

Yes, CDK4/6 inhibitors are increasingly used for hormone receptor–positive cancers. They’re definitely improving survival, and the eligibility criteria are expanding.

We’re also using the Breast Cancer Index (BCI) to help decide whether endocrine therapy should last five or ten years. It’s not appropriate for everyone; patients with lymph node involvement often need ten years regardless, but for some, it can help make a tough decision.

For patients with genetic risk, what’s your approach?

For BRCA1/2 carriers or other high-risk patients, we usually don’t advise chemoprevention because the data is limited. Instead, we do close surveillance, alternating mammogram and MRI.

We avoid mammograms before age 30 because of radiation and because dense tissue makes them less useful. In younger women, we stick to MRI until 30, then add mammography later.

What oncoplastic or reconstructive options are most popular now?

Bilateral reductions are very popular, especially for women with larger breasts who’ve always wanted that option. Our plastic surgery colleagues are excellent, and we do these cases together routinely.

I always ask patients how they feel about their breast size and shape. My perception doesn’t matter if they’re happy. But if they’ve always wanted a reduction, surgery is an opportunity to make that change.

Equity, Innovation, and the Future of Breast Care

Are there still gaps in equity and access?

Yes. I still see patients who haven’t had a mammogram since before COVID. They were in the habit, COVID disrupted them, and they never came back. Some only return because they felt a lump.

But the good news is that we have capacity now. And we have a diverse faculty who can care for patients in many languages—Spanish, Chinese, Italian, Tagalog. I also speak Hindi, and there are more across our group who speak other languages. That’s an important part of access, too.

How do you see AI fitting into breast care?

Nothing is clinically ready yet. I think its biggest potential is predicting treatment response, but it’s not there yet. I’ve been using DAX, the AI scribe. It’s useful, but I’d like it to be smarter. Ideally, I could just say, “Put in a mammogram order,” and it would happen. That’s what would really help in practice.

What misconceptions do you hear most often from patients?

That chemotherapy will make you extremely ill. It’s not true anymore; treatments are much better tolerated.

And that mastectomy is better than lumpectomy. Survival is equivalent, but the cultural perception persists. It’s something I go over carefully with every patient. Bigger surgery isn’t necessarily better.

Looking ahead, what feels most important to you?

The SOUND trial has really complicated shared decision-making in a way. One of the things that makes it a little tricky is that if we're not removing any lymph nodes in the SOUND study, those patients have to get whole breast radiation. But as I mentioned, we now offer partial breast radiation. So, is a patient okay with doing a sentinel node and less aggressive radiation, or would they rather have the longer whole breast radiation, but omit the sentinel node? Those are tough, personal decisions.

And it's hard to say one is better than the other, but you must have some of those conversations, and we do. Ultimately, the goal is more individualized care. Every year, we get closer to tailoring treatment for each tumor and each patient.