Adoption of recommendations to skip sentinel lymph node biopsy (SLNB) in older women with hormone-receptor (HR)-positive, HER2-negative early-stage breast cancer may be slowly gaining traction in the US.

Case in point: Researchers from Main Line Health, which serves the suburban Philadelphia area, reported a steady increase in SLNB omission in their health system between 2021 and 2023, according to a recent analysis presented at the Miami Breast Cancer Conference 2026.

“I was impressed with how much we had improved our omission numbers over the course of those 3 years,” study investigator Kate Brod, DO, breast surgical oncology fellow, with Main Line Health, told Medscape Medical News.

“Although it’s taken a little bit of time for the word to get out and the practice to be adopted, we’re making great strides in lowering the morbidity of our patients by avoiding the sentinel nodes in the patients that aren’t really going to benefit from it,” added William Bradford Carter, MD, breast surgical oncologist, with Main Line Health, who worked on the analysis. 

First issued in 2016, the Society of Surgical Oncology Choosing Wisely recommendation advised against routine SLNB in women aged 70 or older with clinically node-negative, HR-positive, HER2-negative early-stage invasive breast cancer.

The recommendation is supported by randomized trial data, which showed no survival disadvantage and low axillary recurrence rates when SLNB was omitted in these patients.

The Main Line Health study points to a “gradual but persistent” adoption of those guidelines, the researchers said.

Among 364 patients meeting the criteria to omit SLNB, SLNB omission more than doubled over the study period, increasing from 28% in 2021 to 61% in 2023. SLNB use declined in parallel: In 2021, 72% of eligible patients underwent SLNB compared to just 39% in 2023. Predictors of ongoing SLNB use included younger age and earlier year of diagnosis.

The Main Line results align with national data that suggest omission of SLNB is becoming more common, with studies showing a gradual decline in SLNB use among eligible older women since the 2016 Choosing Wisely recommendation.

Many patients, however, still undergo the procedure. For example, an earlier analysis using data from the National Cancer Database found that among eligible older patients, SLNB use declined from 87% in 2012 to 81% in 2019. The study also found that academic programs and high-volume centers had the highest odds of omitting SLNB, whereas facilities in the South and community programs had the lowest odds of skipping it.

In a separate study, 79% of eligible older patients still received lymph node surgery between 2017 and 2020. Another study found that nearly 69% of patients meeting de-escalation criteria still underwent SLNB in 2021.

Carter is not surprised by the slow uptake of the recommendations. 

“For anything that is new, it takes a while for the information to filter out and then get adopted. It may take some time — or convincing — to make sure that the new trend is actually delivering on the expectations that we think it is,” he told Medscape Medical News.

That said, over the last 10 years at least, there has been a significant trend toward de‑escalating treatment, Carter said.

“At tumor boards across the country, oncologists are questioning whether we really need to be as interventional as we have been or is there a way to decrease interventions and still come up with the same results,” he explained.

The study had no commercial funding. Brod and Carter had no relevant conflicts of interest.