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Management of the axilla in early-stage breast cancer

ID: GL 1-23-A Jul 2021
Type of Content: Guidelines & Advice
Document Status: Current
Authors:
M. Brackstone, F. Baldassarre, F. Perera, T. Cil, I. Dayes, J. Engel, A. Kornecki, R. George, S. SenGupta, A. Eisen

Guideline Objective

This guideline is being developed as a joint project, led by the PEBC in collaboration with the American Society for Clinical Oncology (ASCO). It's primary objective is to provide recommendations on the best strategies for the management, and on the best timing and treatment (surgical and radio-therapeutic) of the axilla in early-stage breast cancer.

Patient Population

These recommendations apply to patients with early-stage breast cancer (i.e., stages I, IIA, IIB; and prognostic groups T1, T2, N0, N1mi, N1, M0; and primary tumour size ≤5 cm).

Intended Guideline Users

This guideline is targeted for:

  1. General surgeons involved in the staging of early breast cancer and management of the axilla.
  2. Radiation oncologists involved in the radiation treatment of patients with early-stage breast cancer.
  3. Medical oncologists involved in the systemic treatment of patients with early-stage breast cancer.
  4. Other clinicians involved in the management of women with early-stage breast cancer (e.g., pathologists, radiologists, oncology nurses, genetic counselors).

Research Questions

The proposed research questions will help shed light on appropriate treatments. This will support patients in their decision-making process, and guide physician-patients shared decision-making discussions. In this area the evidence base is evolving and oftentimes the risk is overtreatment, particularly when treatment with neoadjuvant/adjuvant chemotherapy is involved. We devised the following five questions to lead the work of this systematic review and guideline.

Q1. Which patients with early-stage breast cancer require axillary staging (i.e., SLNB, ALND, or US)?

Q2. For women with early-stage breast cancer who did not receive NAC, and are sentinel lymph node negative at diagnosis:

  1. Is further axillary treatment (i.e., radiation, or surgery) indicated?
  2. What sentinel node-negative patient subgroups are most likely to benefit from further axillary treatment with radiation therapy?

Q3. For women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node positive at diagnosis:

  1. Which axillary strategy is indicated?
  2. What sentinel node-positive patient subgroups are most likely to benefit from further axillary treatment either with radiation or with surgery or both?

Q4. For women who were treated with NAC:

  1. If the lymph node is negative at diagnosis, what axillary treatment (i.e., radiation or surgery) is indicated after chemotherapy?
  2. If the lymph node is positive at diagnosis, what axillary treatment (i.e., radiation or surgery) indicated after chemotherapy?
  3. When is the best timing for performing sentinel node excision: prior or following NAC?

Q5. Among patients with early breast cancer appropriate for axillary staging:

  1. Is there a better identification rate with single or dual tracer?
  2. Is there a better identification rate with US-guided SLNB or traditional SLNB?
  3. Is there a better identification rate with US or SLNB?

The Working Group members, in consultation with patient representatives, identified outcomes that are critical to patients. For all questions measures of survival and disease control were considered critical outcomes; quality of life, and adverse events, including surgical complications rate were considered important outcomes.

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