Routine or delayed axillary dissection for primary breast cancer?

Prophylactic lymph node excision has long been recommended for preventing axillary recurrence of primary breast cancer, and has more recently gained support from the finding that adjuvant systemic therapy preferentially benefits patients with axillary node metastases. Despite these justifications, medical opinion in many communities has become deeply polarised over the merits of routine axillary dissection. A factor likely to be contributing to this split is the popularity of prescribing adjuvant systemic therapy (usually tamoxifen) on an expectant basis. Since there has been no controlled assessment of the net benefits of axillary dissection in patients receiving routine adjuvant systemic therapy--followed where necessary by delayed ("salvage") axillary treatment--objective data are urgently needed. If no substantial benefit is lost by replacing routine with delayed dissection, a small but significant improvement in quality of life could be expected for the majority of breast cancer patients.