The recommendation for omission of SLNB in elderly patients is based on the CALGB 9343 study 2 in which only about one-third of patients underwent axillary surgical staging. Without axillary dissection, only 3% (6 of 200) treated with lumpectomy and tamoxifen experienced axillary recurrence. 2 There was no difference in overall survival between treatments with or without radiation therapy (RT), which is the basis for another Choosing Wisely campaign recommendation-omission of RT in elderly patients with stage I ER+BC. What is often overlooked is the characteristics of the patients in CALGB 9343. With a median age of 75 years in both treatment groups, more than 50% in each group had died, most often from non-BC-related causes, on long-term follow-up. 3 Therefore, we agree that omitting SLNB (and RT) is reasonable for patients in their mid-70s and older with significant comorbidities, but it is difficult to broadly apply these recommendations to all patients 70 years and older with stage I ER+BC.Furthermore, axillary staging affects RT recommendations. For fit septuagenarians, accelerated partial breast irradiation (APBI) over 1 week is an excellent way to de-escalate therapy compared with the 5 weeks of RT that was performed in CALGB 9343. However, randomized studies comparing APBI and whole-breast RT required axillary surgical staging. 4 It gives us substantial pause to recommend APBI in the absence of known pN0 status by SLNB, particularly when a patient is hesitant about adjuvant hormonal therapy (HT).This leads to another important assumption when omitting SLNB: that patients will take adjuvant HT. The patientreported HT-related adverse events are not insignificant. Adverse events, such as joint pain and vaginal dryness, can be especially debilitating in elderly patients. The adherence to HT is suboptimal and there is trend for higher likelihood for discontinuing HT early with increasing age. 5 Thus, until better strategies are developed to reduce early discontinuation of HT, understanding the surgical axillary stage in this population will continue to be of importance.