Two experts in breast cancer surgery will explore opposing sides of one of the hottest questions in early-stage breast cancer during the 2025 San Antonio Breast Cancer Symposium^®.

The debate, Do All Early-stage Breast Cancer Patients Need Axillary Staging?, will take place on Friday, December 12, from 2 to 2:50 p.m. CT in Stars at Night Ballroom 1-2 at the Henry B. Gonzalez Convention Center. Melissa Pilewskie, MD, Clinical Associate Professor of Surgery and Co-Director of the Weiser Family Center for Breast Care at the University of Michigan, will argue the affirmative. 

“There is expanding data from the SOUND and INSEMA trials showing no survival benefit or significant impact on regional recurrence when sentinel lymph node biopsy (SLNB) is omitted in clinically node-negative early-stage patients,” Dr. Pilewskie said. “However, nodal pathology for an individual patient may impact the decision for radiation and/or adjuvant systemic therapy recommendations such as CDK4/6 inhibitors or the length of endocrine therapy.”

Walter Weber, MD, Medical Director of Chest, Abdomen, and Pelvis and Chief of Breast Surgery at Basel University Hospital in Switzerland, will argue against universal axillary staging.

“The omission of sentinel lymph node procedures is noninferior oncologically to doing sentinel lymph node procedures,” he said. “And if you omit SLNB, you improve the patient’s quality of life. SLNB should no longer be the standard of care for all patients with clinically node-negative invasive breast cancer.”

Both agree that the results of SOUND and INSEMA clearly show lack of oncologic benefit for universal axillary staging. But those and other trials with similar results have left clinicians in a quandary. Dr. Weber noted that clinical practice is clearly divided in North America and in Europe, where both trials were conducted.

Some experts and centers insist on universal SLNB because it may inform the appropriate use of systemic therapy. Other experts and centers strictly apply SOUND and INSEMA findings and limit SLNB.

“There is quite a bit of data on the omission of axillary staging in women over age 70 with small estrogen receptor-positive breast cancer which has supported the ‘Choosing Wisely’ guidelines that have been present for nearly a decade,” Dr. Pilewskie said. “Despite evidence-based guidelines, more than 70% of women who meet criteria for omission in this older cohort still undergo a SLNB in the United States. Many patients and providers have not been comfortable with SLNB omission despite the lack of survival impact from the procedure and the potential surgical risks.”

It will be important to understand how omitting axillary staging impacts different treatment approaches across different patient populations, Dr. Weber said.

“There is a lot of debate in terms of the impact of sentinel lymph node biopsy omission on radiotherapy, the type of radiation, systemic therapy, CDK4/6 inhibition,” he said. “Can you apply the data to underrepresented populations, such as [patients with] invasive lobular breast cancer, for example? That’s where the real debate lies.”

Combined input and data from the intersections of medical, surgical, and radiation oncology may provide additional clarity about de-escalation decisions, Dr. Pilewskie said.

“One of the biggest limitations in applying SLNB omission into daily practice is that the studies that support this practice and other areas of omission have been done addressing only one discipline in isolation,” she said. “My hope is that the academic community incorporates multidisciplinary de-escalation trials in the future.”