ASO Author Reflections: Preoperative Nomogram Identifies Patients for Selective Omission of SLNB in Breast Cancer—to Promote Implementation of the Choosing Wisely Campaign Recommendations

The idea of omitting axillary surgery in breast cancer treatment is not new. The NSABP B-04 trial 25-year results, published in 2002, found no disease-free or overall survival difference between clinically node-negative women randomized to radical mastectomy versus those randomized to total mastectomy with subsequent axillary lymph node dissection (ALND) only if the nodes became clinically positive.1 This is remarkable, given the 40% prevalence of occult positive nodes in the radical mastectomy arm. Nonetheless, surgical nodal staging (now with sentinel lymph node biopsy [SLNB]) remains entrenched as the standard of care for management of early-stage breast cancer, because nodal status often guides adjuvant therapy. However, SLNB carries up to 6% risk of lymphedema and 9% risk of chronic paresthesia.2 The Society of Surgical Oncology now recommends against the routine SLNB in septuagenarians. However, there is little guidance on what constitutes “routine” SLNB. How can surgeons quantify a patient’s risk of occult nodal positivity? When should SLNB be omitted? …