Abstract
The complexity of managing early stage breast cancer is well known. Optimal treatment is increasingly multidisciplinary and in the modern era informed by sophisticated molecular tools to help select and guide therapy. Major phase III trials have determined that the order of systemic therapy relative to surgery does not influence important endpoints such as event free survival and overall survival (OS), but questions remain as to how best to utilize these most essential services. For example, there is still uncertainty regarding the ideal timing, intensity, and duration of proposed therapy. For treating physicians, evidence based standardization of these practices is both possible and critically important. Optimization of care will increasingly rely on well-designed studies that have addressed the choice as well as the timing of the steps involved in multidisciplinary breast cancer treatment. Understanding when factors under the oncologist's control will influence outcome, cost and convenience is essential in the era of quality and value-based medical decision making. The timing of surgery before or after chemotherapy for breast cancer is one such factor. Investigators are to be commended for addressing these questions, which may generate additional hypotheses concerning the biology of metastasis and the nature of recurrence.