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Past
Surgical management of the axilla in older women with favorable clinically node-negative breast cancer has been widely debated in recent years. In 2016, the Society of Surgical Oncology’s Choosing Wisely Recommendations were published advising against sentinel node biopsy (SNB) in women older than aged 70 years with hormone receptor-positive (ER+/Her2−) invasive breast cancer. These guidelines were based on randomized trials that demonstrated a lack of survival benefit in performing axillary dissection as well as retrospective studies that revealed no difference in survival with SNB omission.1,2,3,4 However, implementation of this practice has been met with challenges because of concerns regarding potential undertreatment and fears of recurrence. Additionally, there is a paucity of prospective data specifically addressing the utility of sentinel node biopsy in this patient population.
Present
This single-institution, prospective study reports 3-year outcomes of 125 patients aged 65 years and older with clinical T1-2N0 ER+/Her2− invasive breast cancer treated with lumpectomy without SNB.5 Median age was 77 years, and median tumor size was 1 cm. Radiation therapy was performed in 29% of patients, and only 48% of patients were taking hormonal therapy at 2-year follow-up. Despite low utilization of adjuvant therapy, estimated 3-year outcomes were excellent with regional recurrence, disease-free survival, and overall survival rates of 98.2%, 91.2%, and 94.8%, respectively at median follow-up of 36.7 months. Noncompliance with hormonal therapy was the only factor on univariable analysis that was associated with any recurrence. This study provides prospective data that de-escalation of axillary surgery often is accompanied by de-escalation of adjuvant therapy and at 3 years is associated with low rates of recurrence or death. While this report was an interim analysis performed before reaching target accrual of 150, the findings thus far provide support for SNB omission in older patients with small ER+/Her2− tumors, although longer follow-up of more patients is critical to concluding the debate on this topic.
Future
With accumulation of prospective data on this surgical approach, greater acceptance of the Choosing Wisely guidelines should be expected. However, the lack of compliance with adjuvant therapies remains a concern. As new treatment strategies for ER+/Her2− breast cancer, such as CDK4/6 inhibitors, emerge, compliance with adjuvant therapy may change, and indications for SNB may need to be reassessed. More than ever, the multidisciplinary collaboration addressing the preferences and tolerability of therapies in this patient population is paramount.
References
Martelli G, Miceli R, Daidone MG, et al. Axillary dissection versus no axillary dissection in elderly patients with breast cancer and no palpable axillary nodes: results after 15 years of follow-up. Ann Surg Oncol. 2011;18(1):125–33. https://doi.org/10.1245/s10434-010-1217-7.
Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA. 2017;318(10):918–26. https://doi.org/10.1001/jama.2017.11470.
Galimberti V, Cole BF, Viale G, et al. Axillary dissection versus no axillary dissection in patients with breast cancer and sentinel-node micrometastases (IBCSG 23–01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol. 2018;19(10):1385–93. https://doi.org/10.1016/S1470-2045(18)30380-2.
Chung A, Gangi A, Amersi F, et al. Not performing a sentinel node biopsy for older patients with early-stage invasive breast cancer. JAMA Surg. 2015;150(7):683–4. https://doi.org/10.1001/jamasurg.2015.0647.
Chung A, Dang C, Karlan S, et al. A prospective study of sentinel node biopsy omission in women age ≥65 with ER+ breast cancer. Ann Surg Oncol. 2024. https://doi.org/10.1245/s10434-024-15000-w.
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This article refers to: Chung A, Dang C, Karlan S, et al. A prospective study of sentinel node biopsy omission in women age ≥65 with ER+ breast cancer. Annals Surgical Oncology. (2024). https://doi.org/10.1245/s10434-024-15000-w.
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Chung, A. ASO Author Reflections: Considerations in the Debate on Sentinel Node Biopsy in Older Patients with ER+/Her2− Breast Cancer. Ann Surg Oncol 31, 3198–3199 (2024). https://doi.org/10.1245/s10434-024-15095-1
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DOI: https://doi.org/10.1245/s10434-024-15095-1