Factors influencing women's preferences and decision making regarding the extent of axillary surgery in breast cancer: A systematic review.

Axillary surgery in early-stage breast cancer is increasingly de-escalated. However, variation in practice persists, and the patient level factors influencing treatment decisions remain unclear. This systematic review synthesised evidence on the psychological, clinical, and contextual factors shaping women's preferences and decision making regarding the extent of axillary surgery they receive. A PRISMA-guided search of Ovid MEDLINE, Embase and Cochrane databases was conducted in December 2025. Ten studies involving 861 women were included, comprising observational, qualitative, and mixed methods designs. Quantitative evidence was limited and heterogeneous, with no consistent clinical or demographic predictors of treatment choice identified. Qualitative findings demonstrated that fear of undertreatment, desire for prognostic reassurance, and trust in clinician recommendation were dominant drivers of decision making. Patients frequently valued additional staging information despite limited survival benefit, and misunderstandings regarding the purpose of axillary procedures were common. No widely implemented, formally validated patient decision aid specific to axillary management was identified. Axillary treatment decisions are primarily driven by patient values and risk perception rather than objective clinical factors. Psychological influences, particularly fear of recurrence and desire for reassurance, may contribute to overtreatment despite increasing evidence supporting de-escalation. Development of validated decision support tools and consistent clinical communication are required to better align surgical care with patient preferences and current evidence.