Sentinel lymph node biopsy in women over 70: Evaluation of rates of axillary staging and impact on adjuvant therapy in elderly women

Published:November 10, 2022DOI:



      The 2016 Society of Surgical Oncology Choosing Wisely guidelines recommended against routine sentinel lymph node biopsy in women ≥70 years old with favorable, early-stage breast cancer, as sentinel lymph node biopsy does not decrease recurrence or mortality in these patients. This study’s objective was to evaluate the use of sentinel lymph node biopsy and its effect on management in elderly patients.


      A retrospective analysis of female patients ≥70 years old with stage I–II, clinically node-negative, hormone-receptor positive, HER2-negative disease undergoing upfront breast cancer surgery between 2017 and 2019. Primary outcome was rate of sentinel lymph node biopsy. Secondary outcome was effect of sentinel lymph node biopsy on adjuvant therapy.


      In total, 142 patients were included. Median age was 76 (interquartile range 73–81), and 71.8% underwent lumpectomy. On final pathology, 57.7% had invasive ductal carcinoma, and median tumor size was 15 mm (interquartile range 10–24.3). A total of 118 patients (83.1%) underwent sentinel lymph node biopsy; of these, 27 (22.9%) were positive for N1mi (7 patients) or N1a disease (20 patients). On multivariate regression analysis, patients undergoing sentinel lymph node biopsy were more likely to be younger (odds ratio 0.87, 95% confidence interval 0.78–0.95). The major risk factor for sentinel lymph node biopsy positivity was lymphovascular invasion (odds ratio 13.4, 95% confidence interval 4.57–40.1). Patients with sentinel lymph node biopsy positivity were more likely to receive local adjuvant radiation therapy (odds ratio 4.66, 95% confidence interval 1.49–16.8) and tended to receive more adjuvant regional radiation therapy (75.0% if sentinel lymph node biopsy positive compared with 15.3% if sentinel lymph node biopsy negative, P < .001).


      Despite the 2016 Choosing Wisely guidelines, more than 80% of patients ≥70 years old underwent sentinel lymph node biopsy at our institution. If sentinel lymph node biopsy was positive, this is associated with over 4-fold higher rates of adjuvant radiation therapy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Oncology SoS. Sentinel node biopsy in node negative women 70 and over 2016.
        • Cassel C.K.
        • Guest J.A.
        Choosing Wisely: helping physicians and patients make smart decisions about their care.
        JAMA. 2012; 307: 1801-1802
        • Hughes K.S.
        • Schnaper L.A.
        • Bellon J.R.
        • et al.
        Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343.
        J Clin Oncol. 2013; 31: 2382-2387
        • Martelli G.
        • Miceli R.
        • Daidone M.G.
        • 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: 125-133
        • International Breast Cancer Study G.
        Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10-93.
        J Clin Oncol. 2006; 24: 337-344
        • Chung A.
        • Gangi A.
        • Amersi F.
        • Zhang X.
        • Giuliano A.
        Not performing a sentinel node biopsy for older patients with early-stage invasive breast cancer.
        JAMA Surg. 2015; 150: 683-684
        • Smith M.E.
        • Vitous C.A.
        • Hughes T.M.
        • Shubeck S.P.
        • Jagsi R.
        • Dossett L.A.
        Barriers and facilitators to de-implementation of the Choosing Wisely® guidelines for low-value breast cancer surgery.
        Ann Surg Oncol. 2020; 27: 2653-2663
        • Giuliano A.E.
        • Edge S.B.
        • Hortobagyi G.N.
        Eigth edition of the AJCC cancer staging manual: breast cancer.
        Ann Surg Oncol. 2018; 25: 1783-1785
        • Giuliano A.E.
        • Ballman K.V.
        • 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: 918-926
        • Carleton N.
        • Zou J.
        • Fang Y.
        • et al.
        Outcomes after sentinel lymph node biopsy and radiotherapy in older women with early-stage, estrogen receptor–positive breast cancer.
        JAMA Network Open. 2021; 4 (e216322-e)
        • Wang T.
        • Baskin A.S.
        • Dossett L.A.
        Deimplementation of the Choosing Wisely recommendations for low-value breast cancer surgery: a systematic review.
        JAMA Surg. 2020; 155: 759-770
        • Tonneson J.E.
        • Hoskin T.L.
        • Durgan D.M.
        • Corbin K.S.
        • Goetz M.P.
        • Boughey J.C.
        Decreasing the use of sentinel lymph node surgery in women older than 70 years with hormone receptor-positive breast cancer and the impact on adjuvant radiation and hormonal therapy.
        Ann Surg Oncol. 2021; 28: 8766-8774
        • Calderon E.
        • Webb C.
        • Kosiorek H.E.
        • et al.
        Are we choosing wisely in elderly females with breast cancer?.
        Am J Surg. 2019; 218: 1229-1233
        • Fish M.L.
        • Grover R.
        • Schwarz G.S.
        Quality-of-life outcomes in surgical vs nonsurgical treatment of breast cancer-related lymphedema: a systematic review.
        JAMA Surg. 2020; 155: 513-519
        • Merchant S.J.
        • Chen S.L.
        Prevention and management of lymphedema after breast cancer treatment.
        Breast Journal. 2015; 21: 276-284
      2. Hrebinko KA, Bryce CL, Downs-Canner S, Diego EJ, Myers SP. Cost-effectiveness of Choosing Wisely guidelines for axillary observation in women older than age 70 years with hormone receptor–positive, clinically node-negative, operable breast tumors. Cancer. 2022;128:2258-2268.

        • Minami C.A.
        • Bryan A.F.
        • Revette A.C.
        • Freedman R.A.
        • King T.A.
        • Mittendorf E.A.
        Oncologists’ perspectives on omission of sentinel lymph node biopsy in women >70 years with early-stage hormone receptor-positive breast cancer.
        J Clin Oncol. 2021; 39: 48
        • Di Lena É.
        • Hopkins B.
        • Wong S.M.
        • Meterissian S.
        Delays in operative management of early-stage, estrogen receptor-positive breast cancer during the COVID-19 pandemic: a multi-institutional matched historical cohort study.
        Surgery. 2022; 171: 666-672
        • Fischer F.
        • Lange K.
        • Klose K.
        • Greiner W.
        • Kraemer A.
        Barriers and strategies in guideline implementation: a scoping review.
        Healthcare (Basel). 2016; 4: 36