Optimizing Axillary Lymph Node Management in Early-Stage HR+/HER2- Breast Cancer: Practical Strategies for Enhanced Detection Rates

<h2>Abstract</h2><h3>Introduction</h3> Abemaciclib is a globally approved, standard-of-care adjuvant treatment for HR+/HER2- high-risk EBC which significantly improved outcomes in combination with ET, versus ET alone, in the pivotal monarchE trial. Nodal involvement is a major adverse prognostic factor in EBC; however, clarity around methods and timepoints for evaluation of involved ALNs and identification of high-risk patients eligible for adjuvant therapy is currently lacking. <h3>Methods</h3> A medical advisory board met virtually in November 2023 to discuss the changing landscape of axillary management in early breast cancer. The discussion assessed the knowledge gap caused by locoregional de-escalation for patients with HR+/HER- EBC leading to challenges in the appropriate identification of eligible patients for adjuvant CDK4/6 inhibitors. The panel aligned on recommendations to address these gaps and summarized these with the intent to raise awareness. <h3>Results</h3> Positive lymph node status can be denoted by pathological <i>or</i> clinical confirmation of breast cancer in ALNs. The panel therefore agreed that pragmatic strategies for ALN evaluation may include less invasive approaches such as ultrasound and clinical assessment. Evaluation of ALNs should be performed expeditiously post-diagnosis and before neoadjuvant treatment. A diagnostic algorithm has been developed to guide clinicians. <h3>Conclusion</h3> Optimized staging and risk assessment in HR+/HER2- EBC is critical to identify high-risk patients eligible for CDK4/6 inhibitors. Implementing these recommendations may improve patient outcomes in the adjuvant setting.