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. 2025 Jul;32(7):4865-4873.
doi: 10.1245/s10434-025-17236-6. Epub 2025 Apr 4.

Axillary Surgery After Neoadjuvant Chemotherapy for Breast Cancer: Population-Based Trends Over Time

Ekaterina Kouzmina  1 , Matthew Castelo  1 , Nicole J Look Hong  2 , Julie Hallet  2 , Natalie Coburn  2 , Frances C Wright  2 , Lena Nguyen  3 , Sonal Gandhi  4 , Katarzyna J Jerzak  4 , Andrea Eisen  4 , Amanda Roberts  5
Affiliations

Axillary Surgery After Neoadjuvant Chemotherapy for Breast Cancer: Population-Based Trends Over Time

Ekaterina Kouzmina et al. Ann Surg Oncol. 2025 Jul.

Abstract

Background: Sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) is recommended for patients initially presenting with cN1 disease and evidence of clinical/imaging response after NAC. We aimed to describe real-world population changes in management.

Methods: We completed a population-based cohort study including adult women undergoing NAC followed by surgery for cT1-3N1 breast cancer between 1 April 2012 and 31 January 2020 in Ontario, Canada. Axillary surgeries (SLNB, axillary lymph node dissection [ALND], or SLNB followed by ALND) were studied over time using the Cochran-Armitage test, while multivariable logistic regression evaluated factors associated with surgery type.

Results: Overall, 2563 patients were analyzed (37.9% were HER2-positive [HER2+ve], 42.3% were hormone receptor-positive and HER2-ve [HR+/HER2-ve], and 19.8% were triple-negative [TN]). 593 (23.1%) patients underwent SLNB and 1860 (72.6%) underwent ALND, while 110 (4.3%) patients underwent SLNB + ALND. From 2012 to 2020, SLNB increased from 5.7 to 29.9% (p < 0.01) and SLNB + ALND increased from 1.7 to 4.7% (p < 0.01), while ALND decreased from 92.6 to 65.4% (p < 0.01). Similar trends were identified across all receptor groups. After adjustment, patients who underwent SLNB had fewer comorbidities (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.03-3.19), smaller tumors (T2 vs. T3: OR 1.52, 95% CI 1.21-1.92; T1 vs. T3: OR 1.56, 95% CI 1.14-2.13), and had surgery later in the study period (OR 1.32, 95% CI 1.25-1.38).

Conclusion: In alignment with current practice guidelines, de-escalation of axillary surgery to SLNB has increased over time for patients after breast cancer NAC.

Keywords: Axillary lymph node dissection; Breast cancer; Hormonal status; Neoadjuvant chemotherapy; Sentinel lymph node biopsy.

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Conflict of interest statement

Disclosures: Katarzyna J. Jerzak reports serving as a speaker/advisory board member/consultant for Amgen, AstraZeneca, Apo Biologix, Daiichi Sankyo, Eli Lilly, Esai, Genomic Health, Gilead Sciences, Knight Therapeutics, Merck, Myriad Genetics Inc., Pfizer, Roche, Seagen, Novartis, and Organon, and has received research funding from Astra Zeneca, Eli Lilly, and Seagen. Sonal Gandhi reports serving on the advisory board for Eli Lilly, Knight, AstraZeneca, and Novartis. Ekaterina Kouzmina, Matthew Castelo, Nicole J Look Hong, Julie Hallet, Natalie Coburn, Frances C. Wright, Lena Nguyen, Andrea Eisen, and Amanda Roberts have no conflicts of interest to declare that may be relevant to the contents of this study.

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