John Benson
Professor John Benson is a Consultant Breast Surgeon at Addenbrooke’s Hospital, Cambridge, Affiliated Assistant Professor, University of Cambridge and Visiting Professor, School of Medicine, Anglia Ruskin University. He qualified from Oxford University Clinical School and has been awarded doctorates from Oxford and Cambridge Universities (DM (Oxon); MD (Cantab)). He received specialist training at the Royal Marsden Hospital and Institute of Cancer Research, London and The New York Hospital-Cornell Medical Centre/Memorial Sloan-Kettering Cancer Centre, New York. He is an examiner for the MRCS examination, a member of the British Breast Group and has recently demitted from the Executive Committee of the Association of Breast Surgery (ABS). His clinical practice is devoted entirely to breast diseases and current research interests include investigation of fluorescence navigation for sentinel lymph node detection in early breast cancer patients (co-investigator for INFLUENCE trial published in Annals of Surgical Oncology). He has been actively involved with the San Antonio Breast Cancer Symposium as a member of the Planning Committee, panellist and Career Development Forum (2011–2015). He was Visiting Professor at the University of Texas, Health Sciences Centre at San Antonio, Texas in December 2016 and is co-convener for the Advanced Skills in Breast Disease Course (ABS course portfolio). He has published more than 160 papers (including 30 in the Lancet/Lancet Oncology) and written/edited 9 books with recent publication of an atlas on diagnosis and management of breast cancer (June 2025). He was elected Honorary Secretary of the Association of Breast Surgery in 2023.
Axilla: Surgical Management
Resection of axillary nodes as an integral component of breast cancer surgery has changed dramatically with a trend towards de-escalation of surgical interventions. A principle motivation for alternatives to standard axillary lymph node dissection (ALND) has been reduction of upper limb morbidity without compromise of oncological outcomes. Introduction of more effective adjuvant treatments including systemic therapy and radiotherapy has facilitated a multi-modality approach in efforts to optimise axillary surgery and avoid over-treatment. The NSABP B-04 trial confirmed that clinically node negative patients could avoid extensive axillary surgery without any survival detriment. It is acknowledged that ALND represents excessive surgery for the majority of cN0 patients presenting within a breast-screened population and increasingly effective systemic therapies with fewer node positive cases and low rates of axillary recurrence. Trials based on sentinel lymph node (SLN) methodology have evaluated whether targeted node sampling can reduce unnecessary axillary surgery with comparable staging accuracy to ALND. These trials have consistently shown that upper limb morbidity is reduced and quality-of-life improved for SLN biopsy alone without impaired survival outcomes. In the setting of multi-modality therapy, residual axillary disease in non-sentinel nodes potentially is eradicated by non-surgical treatments including chemotherapy and anti-HER2 therapies together with loco-regional irradiation. Several non-inferiority trials have confirmed that selective groups of SLN biopsy positive patients can safely avoid further axillary treatment (be this completion ALND or axillary irradiation). Targeted axillary dissection (TAD) can reduce the false negative rate of SLN biopsy following neoadjuvant chemotherapy (NACT) for biopsy-proven node positive patients (cN1). TAD is now being applied in the primary surgical setting for cN1 patients not undergoing NACT where there are no concerns about clip migration consequent to nodal shrinkage as treatment response to NACT.
The culmination of de-escalation strategies is omission of surgery altogether; improvements in adjuvant therapies have contributed to loco-regional disease control and decreased the therapeutic value of axillary node resection. Results of the SOUND and INSEMA trials have ignited interest in omission of SLN biopsy for a broader age range (namely women <70 years).
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