The Natural History of Rejecting Surgery in Breast Cancer

What the Evidence Actually Shows When Patients Choose Alternative Approaches Over Definitive Local Treatment

Yoon Hang Kim, MD, MPH

Board-Certified in Preventive Medicine | Integrative & Functional Medicine Physician

Introduction

Few decisions in oncology carry as much emotional weight as the choice to decline surgery for an operable breast cancer. As a physician who has spent decades in integrative and functional medicine, I understand the deep, human impulse behind that decision. Clients come to me with legitimate frustrations about the conventional medical system. They have read about toxicity, overtreatment, surgical complications, and disfigurement. They want agency over their bodies. They are looking for a different path.

I honor that impulse. But I cannot, in good conscience, remain silent about what the data consistently shows: when surgery is replaced—not supplemented, but replaced—by alternative therapies for operable invasive breast cancer, the outcomes are devastating. The purpose of this blog is not to discourage integrative care. It is to lay out the evidence so that anyone facing this decision can do so with eyes wide open.

Defining Terms: Alternative vs. Complementary vs. Integrative

The terminology in this space is often confused, and the confusion can be dangerous. Alternative medicine refers to unproven therapies used in place of standard cancer treatment—for example, using a restrictive diet, herbal protocol, high-dose IV vitamins, or homeopathy instead of surgery and systemic therapy. Complementary or integrative medicine refers to evidence-informed supportive therapies used alongside conventional treatment—acupuncture for nausea, exercise for fatigue, mindfulness for distress, nutrition support for treatment tolerance.

The distinction is not semantic. It is the difference between a strategy that can meaningfully improve quality of life during cancer treatment and one that, according to every major observational study, is associated with disease progression and death.

The Han et al. Case Series: A Clinical Warning

The most frequently cited study on this topic is by Han and colleagues, published in Annals of Surgical Oncology in 2011.¹ It was a retrospective chart review from a community surgical practice in Portland, Oregon, spanning 10 years. The investigators identified 61 women with breast cancer who refused or delayed recommended conventional treatment in favor of alternative therapies. Median age was 53 years. Median follow-up was 54 months.

The cohort was divided into two subgroups. The surgery subgroup (SSG) included 26 women who declined definitive breast surgery and pursued alternative treatments as their primary approach. The adjuvant subgroup (ASG) included 35 women who underwent surgery but declined recommended postoperative chemotherapy, radiation, or endocrine therapy.

The findings in the surgery-refusal group were stark:

• 96.2% of the 26 women experienced disease progression.
• 50% died of breast cancer during the observation period.
• The average stage at initial presentation was stage II. By the time these women re-presented after using alternative therapies, the average stage was stage IV—meaning the cancer had metastasized.
• The estimated mean 10-year survival with recommended treatment was 69.5%. Their observed survival was 36.4%, despite a median follow-up of only 33 months in that subgroup.

In the adjuvant-refusal group, progression still occurred in 86.2%, and 20% died—a bad outcome, but materially better than the no-surgery group.

The study has real limitations. It is small, retrospective, and without a matched control cohort. Clients self-selected their treatment paths, introducing confounders. The alternative therapies used were not standardized. But the clinical narrative it documents—stage II at diagnosis, stage IV at re-presentation after alternative-therapy delay—is exactly the pattern oncologists have feared, and it has been replicated in larger datasets.

The Geneva Cancer Registry: A Population-Level Confirmation

A stronger, population-based corroboration comes from Verkooijen and colleagues, published in Annals of Surgery in 2005.² This study drew from the Geneva Cancer Registry and included all 5,339 women under age 80 with nonmetastatic breast cancer diagnosed between 1975 and 2000. Of these, 70 women (1.3%) refused surgery. Fourteen percent of the surgery-refusing group did so specifically to pursue alternative therapy.

The survival differences were dramatic:

• Five-year breast-cancer-specific survival was 72% in the surgery-refusal group versus 87% in the surgery-acceptance group.
• Ten-year breast-cancer-specific survival was 36% versus 75%.
• After adjusting for age, tumor size, clinical nodal status, socioeconomic variables, period of diagnosis, and receipt of nonsurgical treatments, surgery refusal was associated with a 2.1-fold higher risk of breast cancer death (HR 2.1, 95% CI 1.5–3.1).

Fourteen of the 70 women who initially refused surgery eventually underwent surgery more than six months after diagnosis, often because of progressive local disease. More than half of the refusal group received no treatment at all. The registry’s longitudinal design and multivariate adjustment make this one of the most methodologically rigorous demonstrations of the harm associated with surgery refusal in breast cancer.

The National Cancer Database: Surgery Refusal Carries the Highest Mortality Hazard

Moya and colleagues published a large-scale analysis in 2021 using the National Cancer Database (NCDB), encompassing over 2 million women with invasive breast cancer.³ The investigators examined the impact of refusing each modality of recommended treatment: surgery, chemotherapy, radiation, and endocrine therapy.

The key finding: surgery refusal carried the highest hazard ratio for mortality among all treatment modalities—HR 2.7 (95% CI 2.5–3.0, p<0.001). By comparison, radiation refusal carried an HR of 1.8, endocrine therapy refusal 1.5, and chemotherapy refusal 1.3. These hazards were independent of race, insurance status, receptor status, and cancer stage.

The scale of this study—over two million clients—provides the kind of statistical power that small case series cannot. The message is consistent: of all the treatment components a client might decline, surgery refusal has the most devastating impact on survival.

The 2026 Yale/NCDB Study: CAM Alone Approaches No Treatment

The most recent and largest study on this question was published by Ayoade and colleagues in JAMA Network Open in March 2026.⁴ This cohort study analyzed approximately 2.16 million women with breast cancer from the NCDB (2011–2021) and stratified them by treatment approach: traditional therapy only, CAM plus traditional therapy, CAM alone, or no treatment.

The results were sobering:

• Five-year overall survival with traditional therapy alone was approximately 90%.
• Five-year survival for the CAM-plus-traditional-therapy group was 81.2%.
• Five-year survival with CAM alone dropped to 60.1%.
• Five-year survival with no treatment was 47.8%.
• After adjustment, the CAM-alone group had a 3.67-fold higher mortality risk compared to the traditional-therapy group (aHR 3.67, 95% CI 3.03–4.44)—nearly identical to the 3.53-fold risk seen in the no-treatment group.

Perhaps equally striking: even clients who combined CAM with traditional therapy had worse outcomes. The data suggested this was driven by lower utilization of radiation and endocrine therapy in the combination group—raising the possibility that pursuing alternative approaches may create a psychological framework in which clients feel justified in omitting parts of their recommended conventional regimen.

As senior author Daniel Boffa, MD, of Yale stated in a commentary, the combination finding was unexpected. There is evidence that complementary modalities can reduce treatment side effects. But the observed pattern suggests that when CAM substitutes for—rather than supplements—components of standard therapy, survival suffers.

Why Biology Does Not Wait

The biological rationale behind these findings is straightforward. Breast cancer is not a static entity. Even a small, apparently indolent primary tumor can acquire the capacity for nodal and distant metastatic spread over time. The window of curability depends on local control—removing or ablating the primary tumor and addressing regional lymph nodes—before the biologic clock runs out.

No diet, supplement, herbal protocol, IV infusion, or mind–body program has been shown in any controlled study to eradicate an established invasive breast cancer. The National Cancer Institute states that no studies demonstrate that a particular diet, food, vitamin, mineral, supplement, herb, or combination can slow cancer, cure it, or prevent its recurrence. When these approaches are used as the primary anticancer strategy, the tumor continues its biologic progression unchecked.

The stage migration documented in the Han study—from stage II at diagnosis to stage IV at re-presentation—illustrates this principle in human terms. Once breast cancer has metastasized, it is usually treatable but generally not curable with present therapies. The shift from curative to palliative intent is, in most cases, irreversible.

The Legitimate Nonoperative Pathway: A Fundamentally Different Question

There is a scientifically credible line of investigation exploring whether surgery can be safely omitted after standard neoadjuvant systemic therapy has achieved a pathologic complete response (pCR). This is not alternative medicine. It is evidence-based de-escalation within a rigorous multidisciplinary framework.

The best-known modern work involves early-stage triple-negative or HER2-positive cancers—subtypes with relatively high pCR rates after appropriate neoadjuvant chemotherapy and targeted therapy. In a phase II multicenter study led by MD Anderson, 31 highly selected clients with image-guided vacuum-assisted biopsy-confirmed pCR after neoadjuvant systemic therapy received whole-breast radiation without breast surgery. At a median follow-up of 26.4 months, no ipsilateral breast tumor recurrences occurred.⁵ Subsequent longer-term follow-up analyses of this cohort have continued to show favorable outcomes, though these remain limited to a highly selected trial population.

This result is promising, but the caveats are substantial:

• It is a small, single-center, nonrandomized cohort.
• It depended on modern systemic therapy, rigorous imaging, image-guided vacuum-assisted biopsy of the clipped tumor bed, multidisciplinary selection, and radiation.
• It does not generalize to ER-positive/HER2-negative tumors, which typically have lower pCR rates.
• Prospective trials such as the OPTIMIST trial are ongoing and have not yet reported definitive results.

The critical distinction: this pathway uses evidence-based systemic cancer treatment to eliminate the tumor, then confirms its absence with sophisticated biopsy and imaging before omitting surgery. It is the opposite of substituting an unproven regimen for local control.

Where Integrative Care Provides Real Value

None of the data above argues against integrative medicine as a supportive strategy. An evidence-oriented integrative plan can be enormously valuable when deployed alongside—not instead of—oncologic treatment:

• Exercise and rehabilitation for cancer-related fatigue, physical function, mood, cardiometabolic health, and long-term survivorship.
• Dietitian-led nutrition support to preserve lean mass, manage treatment-related GI effects, and support immune and metabolic function—which is fundamentally different from trying to "starve" a tumor with a restrictive diet.
• Mindfulness-based stress reduction, cognitive behavioral therapy for insomnia (CBT-I), yoga, and supportive counseling for anxiety, sleep disruption, depressive symptoms, and coping.
• Acupuncture or acupressure for chemotherapy-induced nausea, pain, aromatase-inhibitor-associated musculoskeletal symptoms, and vasomotor symptoms.
• Medication–supplement reconciliation, because certain botanicals and concentrated supplements can interact with endocrine therapy, chemotherapy, anticoagulants, anesthesia, or radiation.

These complementary interventions can reduce symptom burden, improve treatment adherence, and enhance quality of life. They should never be presented as antitumor substitutes.

Clinical Bottom Line

For any client with operable invasive breast cancer who is considering avoiding surgery, the most important next step is a thorough breast surgical oncology and medical oncology review of the exact pathology and staging: histology, ER/PR/HER2 status, grade, tumor size, nodal status, imaging findings, germline risk, and treatment response if neoadjuvant therapy has already begun.

For most operable invasive cancers, standard local management remains breast-conserving surgery plus radiation when appropriate, or mastectomy in selected situations. A legitimate nonoperative pathway should be offered only within a formal clinical trial or equivalent expert-center protocol after a documented exceptional response to standard systemic treatment—not as a substitute based on alternative medicine claims.

The data is unambiguous: replacing surgery with alternative therapy for operable breast cancer is associated with disease progression, stage migration, and markedly worse survival. As integrative physicians, our role is to deploy complementary strategies that support clients through treatment—not to replace the treatments that save their lives.

Important: This blog is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Every cancer is biologically unique. Decisions about surgery, systemic therapy, and supportive care should be made in close partnership with a qualified oncology team that understands your specific pathology, staging, and clinical context. If you or someone you love is considering declining recommended treatment, please seek a multidisciplinary oncology consultation before making that decision.

References

1. Han E, Johnson N, DelaMelena T, Glissmeyer M, Steinbock K. Alternative therapy used as primary treatment for breast cancer negatively impacts outcomes. Ann Surg Oncol. 2011;18(4):912–916. doi:10.1245/s10434-010-1487-0. PMID: 21225354.

2. Verkooijen HM, Fioretta GM, Rapiti E, et al. Patients’ refusal of surgery strongly impairs breast cancer survival. Ann Surg. 2005;242(2):276–280. doi:10.1097/01.sla.0000171305.31703.84. PMID: 16041219.

3. Moya JJ, Moazzez A, Ozao-Choy JJ, Dauphine C. Patients with invasive breast cancer who refuse treatment: an analysis of associated factors and impact on survival. Am Surg. 2021;87(10):1627–1632. doi:10.1177/00031348211024170.

4. Ayoade OF, Caturegli G, Canavan ME, Resio BJ, Berger ER, Boffa DJ. Use of complementary and alternative medicine in the management of breast cancer. JAMA Netw Open. 2026;9(3):e260337. doi:10.1001/jamanetworkopen.2026.0337.

5. Kuerer HM, Smith BD, Chavez-MacGregor M, et al. Eliminating breast surgery for invasive breast cancer in exceptional responders to neoadjuvant systemic therapy: a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2022;23(12):1517–1524. doi:10.1016/S1470-2045(22)00613-1.

6. Joseph K, Vrouwe S, Engel D, et al. Outcome analysis of breast cancer patients who declined evidence-based treatment. World J Surg Oncol. 2012;10:118. doi:10.1186/1477-7819-10-118.

7. Johnson SB, Park HS, Gross CP, Yu JB. Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncol. 2018;4(10):1375–1381. doi:10.1001/jamaoncol.2018.2487.

In health,

Yoon Hang Kim, MD, MPH

About Dr. Kim

Yoon Hang Kim, MD, MPH, is a board-certified Preventive Medicine and Integrative & Functional Medicine physician. He completed an Integrative Medicine Fellowship at the University of Arizona under Dr. Andrew Weil, holds UCLA Medical Acupuncture certification, and is an IFM Scholar. His clinical specialties include integrative oncology, neuroimmunology, and complex chronic disease. He is the author of three books and more than 20 peer-reviewed and clinical articles. His practice focuses on evidence-based, client-centered integrative care.

Professional: www.yoonhangkim.com  |  Clinical: www.directintegrativecare.com