Using the National Cancer Database (NCDB), we evaluated national trends in axillary surgery management in patients with pathologic T0–T2 estrogen receptor positive (ER+) human epidermal growth factor receptor 2 negative (HER2−) breast cancer with 3–5 positive lymph nodes who underwent surgery followed by adjuvant systemic and radiation treatments, and the impact of SLNB versus ALND on OS in this patient population. Here, ESR1 is linked to breast cancer.