3
Management
I. Staging
➤ For patients ≥70 years of age with clinically node-negative (T1N0)
early-stage invasive breast cancer that is hormone receptor positive
and HER2 negative, sentinel lymph node bioposy (SLNB) is NOT
required. (Moderate Recommendation; IC-B-Ins)
• This is supported by the Choosing Wisely statement released on July 12, 2016, and
updated on June 20, 2019 by the Society of Surgical Oncology (SSO) available at:
http://www.choosingwisely.org/clinician-lists/sso-sentinel-node-biopsy-in-node-
negative-women-70-and-over/ that stated: "Don't routinely use sentinel node
biopsy in clinically node negative women ≥70 years of age with early stage hormone
receptor positive, HER2 negative invasive breast cancer" if they will be treated with
hormonal therapy. If omission of SLNB is considered, a consultation with a medical
oncologist can be considered before surgery to discuss hormonal therapy.
➤ For patients <70 years of age without significant competing
comorbidities, SLNB should be considered for axillary staging of
early-stage breast cancer. (Strong Recommendation; EB-B-I-H for
staging by axillary lymph node dissection (ALND) versus no ALND;
Ins for staging by SLNB versus no staging)
Qualifying Statements for Staging:
• The information acquired from SLNB would be helpful in guiding adjuvant
treatment decision making.
• Patients should be evaluated on a case-by-case basis to ensure appropriate patient-
centered decision making.
• Patients who are clinically node-negative on physical examination but are found
to be sonographically abnormal on imaging with or without confirmatory biopsy
can be offered SLNB as first-line axillary staging.
II. Further Axillary Treatment: SLN(-)
➤ Clinicians should NOT recommend ALND for women with early-
stage breast cancer who do not have nodal metastases.* (Strong
Recommendation; EB-B-I)
➤ In some selected patients (e.g., patients with medially or centrally
located tumors or with high-risk features), and using a patient-
centered approach, it is reasonable to offer the option of loco-regional
nodal irradiation (LRNI) to include at least the supraclavicular and
ipsilateral internal mammary lymph nodes in addition to the breast
and/or chest wall (see Qualifying Statements).
For the majority of patients (i.e., node-negative patients whose tumors
are not medial or central in location and who do not have other high-
risk features), we cannot recommend LRNI. A risk-benefit discussion
should be undertaken on a case-by-case basis for these patients (see
Qualifying Statements). (Weak Recommendation; EB-B-I-L)
* Endorsed from Lyman GH, et al. J Clin Oncol. 2017;5:561-4, Recommendation 1
