Many older female patients are undergoing sentinel lymph node biopsy – even when they meet the criteria to skip that step. Novant Health is spearheading an effort to decrease unnecessary biopsies where clinically warranted.
The background: The American Society of Breast Surgeons (ASBrS) Choosing Wisely recommendation advises against routine sentinel lymph node biopsy (SLNB) for women aged 70 years and older with clinically node-negative, early-stage, hormone receptor–positive breast cancer when results are unlikely to change systemic therapy decisions. The goal is to safely de-escalate axillary surgery — reducing morbidity without compromising oncologic outcomes.
Despite national guidance, many eligible patients still undergo SLNB out of habit, perceived medicolegal risk or concern that nodal status will alter treatment.
Peter Turk, MD, breast surgeon with Novant Health, shared how the team operationalized the ASBrS Choosing Wisely criteria across multiple sites and what referring clinicians should know when counseling and referring older patients with early-stage disease. Elizabeth White, cancer outcomes analyst, was a key driving force behind the Novant Health initiative — helping surface the opportunity, align stakeholders, and support ongoing measurement and feedback to sustain practice change.
We asked Dr. Turk to explain why skipping the sentinel lymph node biopsy is wise in some breast cancer cases.
Q: What are the key factors that led to the adoption of the ASBrS “Choosing Wisely” criteria for avoiding sentinel lymph node biopsy in women aged 70 and older with early-stage breast cancer?
A: We know that women over age 70, with small (2 cm or less), slowly growing, hormone-sensitive breast cancers have a low risk of lymph node involvement. If the preoperative axillary (underarm) ultrasound shows no abnormal lymph nodes, omitting the pathologic evaluation of the lymph nodes does not decrease the survival or increase the local recurrence rates.
Q: How has the implementation of these criteria impacted clinical practice and patient outcomes at Novant Health compared to previous years?
A: Despite the national guidelines being in place since 2017, omission (“Choosing Wisely”) rates are only 10% nationally. We made a Novant Health Quality Improvement initiative in early 2025, to increase the adherence to this standard across the system (including the centers in Charlotte, Winston-Salem and Wilmington). From 2017 through 2023, 91.5% of patients eligible for avoiding the lymph node biopsy completed the procedure. With the Novant Health Breast Cancer committee focused on this discrepancy, in 2025, this procedure was completed on only 13.3% of cases in the system (47 out of 354 patients), a radical improvement.
Q: What are the main benefits for patients when sentinel lymph node biopsy is avoided, particularly regarding anesthesia, pain, recovery time and risk of lymphedema?
A: Avoiding the sentinel lymph node biopsy allows the patient to be sedated, without requiring general anesthesia for the lumpectomy. “Choosing wisely” avoids the common postoperative underarm pain and numbness (which can be long-term) and prevents the risks of lymphedema.
Q: Are there specific circumstances or patient characteristics where sentinel lymph node biopsy may still be recommended for women 70+ with early-stage breast cancer?
A: In patients with fast-growing tumors, those that are hormone-resistant, and may need chemotherapy, as well as those over 2 cm in size or in whom the preoperative ultrasound identifies an abnormal lymph node, the assessment is still indicated. Also, if a mastectomy is planned, the sentinel lymph node biopsy is still recommended.
Q: How does the rapid adoption of de-escalation of care at Novant Health reflect broader trends in national guidelines and cancer care?
A: Nationally, we are now looking at women less than 70 years of age, in attempts at avoiding this painful procedure. We have data that shows similar results in younger patients avoiding the lymph node evaluation, and at Novant Health, we have a current Quality Improvement initiative to ensure a discussion of avoiding this procedure in patients 60 to 70 years of age, with similar criteria.
Q: What data or metrics are being tracked to assess the effectiveness and safety of this change in practice, and what have the results shown so far?
A: We continue to follow the documentation of discussion of “choosing wisely” criteria in patients, and the reasons for completing the lymph node assessment (usually patient-driven).
Cancer care with shorter treatments & fewer side effects
Q: What advice would you give to referring physicians when considering patient referrals for women aged 70+ with early-stage breast cancer under these new guidelines?
A: I would reassure the patients we are on the leading edge of safely de-escalating the care for the newly diagnosed cancer patient, with considerations of avoiding radiation, chemotherapy or more aggressive surgery, in order to maximize their overall health, and limiting the morbidity of breast cancer treatment. Knowing that the transition from radical mastectomy to modified radical mastectomy, and then mastectomy to lumpectomy took many years nationally, this rapid transition of care is an example of the benefit of coordinated multidisciplinary efforts.
