[Comment] Time to abandon axillary lymph node dissection in early-stage breast cancer

Over the past 50 years, the management of the axilla has drastically shifted towards less extensive surgery because of the absence of survival benefit and increased morbidity that occurs with axillary lymph node dissection (ALND) in patients with early stage breast cancer.1–3 The ability to de-escalate axillary surgery has been made possible by the understanding that tumour biology is the primary driver of prognosis, decreasing the reliance on nodal status for systemic therapy decisions. For over a decade, following publication of the ACOSOG Z0011 trial in 2011,4 oncologists became accustomed to making decisions on whether to proceed with systemic therapy for node-positive patients without the need for an ALND, despite uncertainty about additional nodal involvement.