Axillary management in older women with early operable invasive breast carcinoma: a narrative review

Background and Objective: Breast cancer management in older women presents challenges due to competing comorbidities and life expectancy concerns. Traditional axillary surgeries as part of treatment of breast cancer are being reconsidered, particularly in two settings (I) early operable disease with positive sentinel lymph node biopsy (SLN+) and (II) cases of early operable clinically node-negative disease (cN0). Current guidelines and emerging evidence suggest that axillary lymph node dissection (ALND) may not always be necessary, especially in patients with low-risk disease. The objective of this study is to offer an updated synthesis of current guidelines and discuss the latest evidence from significant clinical studies. Methods: A literature search was conducted using the PubMed database and articles up to Nov 2023 were included for analysis. Key Content and Findings: Recent trials, including AMAROS and OTOASOR, demonstrate the non- inferiority of radiotherapy compared to ALND in early breast cancer with positive sentinel lymph node biopsy (SLNB), offering a shift towards de-escalation of axillary surgery. Similarly, studies like IBCSG 10- 93 highlight the potential benefits of omitting axillary surgery in clinically node-negative tumours, showing improved quality of life without compromising oncological outcomes. Despite promising findings from these studies, challenges remain, including disparities between real-world evidence and controlled trials. Variation in clinical management persists, influenced by factors such as trials designs, restricted inclusion criteria, and clinician interpretation. Ongoing trials are still needed to further elucidate the role of axillary surgery, particularly in older women, by assessing quality of life outcomes, the need for comprehensive geriatric assessment tools, and individualised treatment decisions. Conclusions: While evidence supporting the use of radiotherapy or adjuvant systemic therapy for managing axillary lymph nodes continues to grow, the reduction in both ALND and SLNB in older women may be on the horizon, emphasising the importance of tailored treatment approaches based on patient characteristic.