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Implementing clinical practice guidelines for breast cancer management: searching for homogeneity in real-life heterogeneity

Breast cancer is one of the most common solid tumors in the world and a major cause of premature mortality among women (1). Despite the notable progresses and the high efficacy of diagnostic tools and multimodal treatment strategies (surgery, radiotherapy and medical treatments) in early disease, up to a third of breast cancer patients still recur and die (2). Breast cancer encompasses a broad spectrum of different situations and various clinical challenges, depending on the specific cancer histology, tumor grade, disease stage and definition of the molecular subtype (luminal A, B, Triple-negative/basal-like, HER2enriched). Obviously, the clinical context can also change according to the characteristics of the patient, such as age, menopausal state, comorbidities, without neglecting specific clinical conditions as male breast cancer, concomitant pregnancy, or the presence of genetic anomalies of cancer predisposition (namely BRCA 1 and 2 mutations). Moreover, breast cancer represents a crucial commitment for healthcare institutions (governmental organizations, scientific societies), to ensure adequate information, clear management indications and, sometimes, “reassurance” towards health workers, patients and their families, but also public opinion. Their need for information, as clear and concise as possible, requires an explanation about the quality of evidence and the expression of the strength of recommendations, easily exploitable. Clinical practice guidelines are statements that include practical resolutions and management proposals intended to optimize patient care outcomes and efficiencies, but also to minimize disparities. They are structured according to a systematic review of evidence-based knowledge, assessing the benefits and harms of alternative care options and taking into account the actual availability of suggested choices, in the specific context of application. Increasing evidence showed that adherence to guidelines is associated with improved outcomes in patient care, as well as prolonged survival and better quality of life (3). However, in recent years, concrete availability of real life medical resources has become a major concern in clinical practice guidelines, and this is particularly important for developing countries or socioeconomically diverse communities. China is one of the most important developing countries, with a large territory and uneven economic and academic developments. Conceiving and implementing a consensus document on diagnosis and treatment of breast cancer, applicable to different territorial realities and capable of summarizing the perspective of the Chinese Society of Clinical Oncology (CSCO), is a truly ambitious challenge. Indeed, the CSCO guidelines must consider differences in regional development, namely with regard to the availability of medical compounds and diagnostic tools, without forgetting the social value of cancer treatment. Moreover, since a vast amount of data and knowledge revealed the genomic bases of breast cancer heterogeneity, it is important to take into account the advances in precision medicine, as the genomic “revolution” gradually translates into clinical practice (4). The publication of the updated CSCO guidance on diagnosis and management of breast cancer in 2020 could Editorial