Open Access The first obstacle is imaging. Ultrasound, MRI, and PET scan, are used to evaluate this complete response and, depending on the team and the false negative rate varies between 10 and 30%. 6 The importance of imaging and the possibility of identifying suspicious axillary nodes radiologically by clips is not universally available due to the cost of these examinations. 13 Patients must then undergo active, regular and prolonged surveillance, which can become very distressing for patients when changes in breast or axillary images appear. Here again, the cost of these repeated examinations is not negligible.

Finally, there is still insufficient experience with this type of strategy to make it widely available. Monica Morrow, from the Memorial Sloan Kettering Center in New York, humorously said, "What is the problem with doing a lumpectomy with a sentinel lymph node, which provides precise information on the histological response, makes it possible to evaluate the margins of the excision, lasts less than an hour, is inexpensive and therefore makes it possible to make a correct evaluation with a serene followup?" 7 In addition, neo-adjuvant treatment remains disappointing in terms of complete histological response in the majority of luminal A and B cancers and lobular cancers. In that case, this non-operative attitude must still be accepted with caution and if it is adopted, patients must still be included in therapeutic trials to validate this approach. Also, neoadjuvant strategy is not applicable in intra ductal cancers (In situ Carcinomas). The ultimate goal of a multidisciplinary approach should not be to not operate but to apply to each patient the treatment that will give her the best survival with the minimum of physical and psychological sequelae. 8 However, oncology is constantly evolving, and in radiotherapy, the COVID pandemic helped to develop hypo-fractionation decreasing the six weeks treatment to 15 fractions and even 5 fractions in the fast and fast forward trials in post-operative treatment. 9 Obviously, in case of conservative treatment, irradiation becomes necessary and discussions may arise on the benefitof the boost on the site of the tumor that has disappeared. 10 More recently, localized partial irradiations, (APBI) associated with medical treatment have made it possible to obtain complete responses in some patients.

The recent explosion of new molecules on the market, such as immunotherapy, CDK4/6 inhibitors, and conjugated antibodies, have temporarily eliminated the notion of medical de-escalation. 10 Their exact interferences in these molecules and surgery remain to be discovered.

The molecular approach, where each patient and each tumor can benefit from NGS (New Generation Sequencing) associated with the study DNA and/or analysis of circulating cells, is close at hand. Still limited by costs, this approach, coupled with local and regional treatments and "real life" parameters, will impose the use of artificial intelligence in our diagnostic and therapeutic parameters. 11 Surgery will not disappear any more than neoadjuvant treatments have made it disappear. Surgeons will have to learn and find their place among the myriad of research projects that are underway, and while their historical role as the first line of treatment for solid tumors will diminish, their task will change, provided only that they keep abreast of developments.

To repeat the first part of this editorial, the increase in the number of cancer cases and the decrease in the number of surgeons and anesthetists to treat them will be an urgent challenge for our supervisors. In France, these authorities are more concerned with legislating on the authorizations of centers than with training, in particular the breast surgeons of the future, while there are more than 60,000 new cases of breast cancer per year. Senology, after having belonged to "general" surgery, has passed into the field of gynecology where the means are shared between childbirth, peri-fetal medicine, fertility, etc. This is not the case in all countries, but there is an urgent need to train, especially to promote this complex surgery, to attract future young colleagues.

Failure to provide this training could result in a two-tier system between countries and institutions that are capable of modern management and those where, because of lack of screening, patients will arrive with advanced forms of the disease and will not have the means to access modern treatments. As Dr. Fabrice André, the president of ESMO presented in the annual congress of ESMO 2022, "In the next five years, we will need more doctors, surgeons and nurses, with more healthcare and diagnostic infrastructure, to take care of the growing number of patients who will have benefited from "multiple" detection tests."