Assessing Nodal Positivity in Men 70 Years of Age and Older With Clinically Node Negative Hormone-Receptor Positive Breast Cancer to Guide Axillary Intervention

Background Choosing Wisely Guidelines recommend against routine sentinel lymph node biopsy (SLNB) for early-stage, hormone-receptor positive (HR+), clinically node negative (cN0) breast cancer (BC) in elderly women. To determine the applicability of this guideline to men, we evaluated pathologic nodal positivity (pN+) between men and women with low-risk HR+, cN0 BC. Methods The National Cancer Database was queried for patients ≥70 years who underwent surgical resection for low-risk, HR+, cN0 BC. Low-risk was defined as grade 1, cT1mi-T1c or grade 2, or cT1mi-T1b. pN+ was evaluated and compared by sex. Results Of 708 men and 123 855 women, 13.0% of men were pN+ compared to 7.7% of women ( P < 0.001). Men presented with older age, more comorbidities, advanced stage, lymphovascular invasion, tumor upstaging, and a higher nodal burden (all P < 0.001). Men were more likely to undergo axillary lymph node dissection ( P = 0.002), but there were no differences in adjuvant chemotherapy or endocrine therapy between pN+ men and women. There were no differences in 5-year overall survival (84.0% vs 85.3%, P = 0.80). Discussion Men ≥70 years with low-risk cN0 breast cancer have nearly double the rate of nodal positivity compared with women, indicating that SLNB omission cannot be directly extrapolated from female-based guidelines and should instead be considered on an individualized basis.