News|Articles|March 6, 2026

Fewer Lymph Node Biopsies for Older Women With Early Breast Cancer

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Key Takeaways

Society of Surgical Oncology Choosing Wisely discourages routine SLNB in women ≥70 years with cN0, HR-positive/HER2-negative invasive disease, supported by CALGB 9343 and PRIME II showing no survival decrement.
National de-implementation has been modest despite 2016 guidance, with NCDB showing SLNB rates declining from 86.7% (2012) to 81% (2019) and lower omission in Southern and community settings.
Main Line Health demonstrated rapid practice change, shifting from 72% SLNB in 2021 to a majority omission strategy in 2023 (61% omitted; 39% performed).
Younger eligible patients and earlier treatment years were more likely to receive SLNB, indicating residual clinician or institutional preference effects within a guideline-concordant cohort.
Higher utilization of preoperative imaging and Oncotype DX among SLNB patients suggests parallel intensity of workup and highlights tradeoffs between avoiding surgical morbidity and losing axillary prognostic data.

New data show more women over 70 are safely skipping sentinel lymph node biopsies for HR+ breast cancer, reducing unnecessary surgery and risks.

Fewer older women with early-stage, hormone receptor (HR)-positive, HER2-negative breast cancer are undergoing routine sentinel lymph node biopsy (SLNB), according to data that were presented at the 43rd Annual Miami Breast Cancer Conference, held March 5 to 8, 2026.

Researchers from Main Line Health (MLHS) reported a significant shift in surgical practice over a three-year period, aligning more closely with Society of Surgical Oncology (SSO) Choosing Wisely (CW) recommendations.

A Shift in Surgical Standards for Patients With Breast Cancer

The SSO Choosing Wisely CW initiative advises against routine SLNB in specific populations, particularly women aged 70 years and older with clinically node-negative, HR-positive, HER2-negative invasive breast cancer. This recommendation is supported by randomized trial data, such as the CALGB 9343 and PRIME II trials, which demonstrated that omitting axillary staging in these patients does not result in a survival disadvantage and is associated with low rates of axillary recurrence.

Despite this high-level evidence, national de-implementation has historically been slow. A 2025 article published in Breast Cancer Research and Treatment analyzed National Cancer Database (NCDB) data and found that while SLNB use in women over 70 declined from 86.7% in 2012 to 81% in 2019, rates remained high despite the 2016 CW guidelines. That study identified that academic programs and high-volume centers were more likely to omit SLNB, whereas facilities in the South and community programs had lower rates of de-implementation.

MLHS Institutional Trends

The study presented at MBCC assessed the performance of SLNB at MLHS between 2021 and 2023, specifically evaluating 364 patients who met the CW criteria: age 70 or older, invasive ductal or lobular carcinoma, clinically node-negative status, HR-positive and HER2-negative.

The results indicated a progressive and persistent adoption of the guidelines:

2021: 72% of eligible patients underwent SLNB, while only 28% had the procedure omitted.
2022: The gap narrowed, with 59% receiving SLNB and 41% omitting it.
2023: For the first time, omission became the majority practice, with 61% of patients skipping the procedure compared to 39% who underwent it.

Predictors and Clinical Implications

The investigators identified younger age and an earlier year of diagnosis as primary predictors for undergoing SLNB. Notably, patients who underwent SLNB were also more likely to have received additional preoperative imaging and Oncotype DX testing. This suggests that factors beyond age and tumor phenotype, such as institutional culture or physician preference, continue to influence the decision-making process.

This institutional progress at MLHS contrasts with the modest national declines reported in the 2025 NCDB analysis. However, clinicians must still weigh the benefits of omission against the potential loss of information for adjuvant therapy.

Conclusion

The MLHS data suggests that localized efforts can successfully drive the de-implementation of low-value surgical procedures. While the transition is gradual, the trend at MLHS indicates that the CW guidelines are becoming the standard of care for older patients with low-risk breast cancer, reducing the morbidity of surgery without compromising overall survival.

“Adoption of CW guidelines is gradual, but persistent across MLHS,” researchers wrote in the poster. “Predictors of SLNB were younger age and earlier year of diagnosis. Those undergoing SLNB were more likely to have additional preoperative imaging and oncotype testing, suggesting factors besides age and tumor phenotype may influence the decision for SLNB.”

References:

“Implementation of Choosing Wisely recommendations for omission of sentinel lymph node biopsy” by Dr. Stephanie Kjelstrom et al., poster presented at: 43rd Annual Miami Breast Cancer Conference; March 5-8, 2026, poster 23.
“Multi-level factors drive use of sentinel lymph node biopsy in older women with early-stage breast cancer” by Dr. Madeline B. Thomas et al., Breast Cancer Research and Treatment.

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