Current practices and trends of axillary surgery de-escalation and lymphedema management for breast cancer in China: a nationwide cross-sectional survey

BACKGROUND: Axillary management in breast cancer has evolved toward de-escalation to reduce complications, particularly breast cancer-related lymphedema (BCRL). This study aimed to assess current practices and trends of axillary surgery and BCRL management in China. METHODS: A nationwide survey was conducted across hospitals performing ≥ 200 breast cancer surgeries annually in 2022. The questionnaire evaluated institutional characteristics, clinical practices of axillary surgery and BCRL care. Data were compared with those from the 2017 national survey involving 110 hospitals to assess temporal changes in hospital-reported practice patterns. RESULTS: The 198 hospitals surveyed performed a total of 123,237 breast cancer surgeries in 2022. SLNB for cN0 patients was routine practice, with 59.6% of hospitals performing SLNB in > 90% of these cases, whereas the use of SLNB in patients with clinically suspicious axillary nodes and FNA-confirmed metastasis remained cautious. The omission of ALND for patients with limited SLN metastasis (1-2 positive SLNs) remained conservative, particularly for mastectomy cases. However, significant increases were observed compared with the 2017 survey (breast-conserving surgery: median 30.0% vs. 9.0%, P = 0.001; mastectomy: median 11.0% vs. 6.6%, P < 0.001). The timing of SLNB in patients receiving neoadjuvant chemotherapy (NAC) shifted toward the post-NAC setting compared with 2017 (54.0% vs. 45.5%). Comprehensive assessment after NAC, including targeted axillary dissection (TAD) with dual-tracer mapping, was underutilized (23.7%). Hospital-reported BCRL care teams had been established in 52.0% of hospitals, while surgical BCRL interventions remained rare (11.6%). CONCLUSION: Compared with the 2017 national survey, hospital-reported adoption of axillary de-escalation strategies in China was broader, although implementation remained cautious and uneven across clinical scenarios and institutional settings. As a hospital-level practice-mapping survey, this study describes implementation patterns rather than patient-level oncologic safety or efficacy. These findings suggest that tracer accessibility, evidence-based protocols, and multidisciplinary BCRL care may be important areas for future improvement.