# ALMANAC (Axillary Lymphatic Mapping Against Nodal Axillary Clearance)

Source: https://onco.cc/trials/almanac/  
OnCo record `almanac` (Trial). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The British half of the sentinel node question, and the one that measured what patients actually feel. A year after surgery, arm swelling had fallen from about one woman in eight to one in twenty, and numbness from about one in three to one in nine.

## Summary

ALMANAC randomised 1,031 patients with clinically node-negative invasive breast cancer to sentinel lymph node biopsy (515) or to standard axillary treatment (516) between November 1999 and October 2003. Unlike NSABP B-32 it made arm and shoulder morbidity and quality of life the primary outcomes, on the reasoning that the survival question was being answered elsewhere and the morbidity question was the one patients were asking.

At twelve months the relative risk of any lymphoedema in the sentinel node arm was 0.37 (95 percent confidence interval 0.23 to 0.60), an absolute fall from 13 to 5 percent, and the relative risk of sensory loss was 0.37 (0.27 to 0.50), from 31 to 11 percent. Drain use, length of stay and time to resumption of normal activities were all significantly lower (p<0.001 for each), and axillary operating time fell (p=0.055). Patient-recorded quality of life and arm function were better throughout (p at or below 0.003), with no increase in anxiety.

ALMANAC is why the sentinel node case is usually made in terms of harm avoided rather than benefit gained. The cancer outcome is the same; what changes is whether a woman can lift her arm, feel her upper inner arm, and avoid a sleeve for the rest of her life.

## Fields

- Kind: Trial
- Status: positive
- Last checked: 2026-09-25
- Also known as: ALMANAC trial
- Phase: 3
- Setting: Operable invasive breast cancer with clinically negative nodes: sentinel node biopsy against standard axillary treatment, with arm and shoulder morbidity and quality of life as the primary outcomes
- Sponsor: Cardiff University and the United Kingdom ALMANAC Trialists Group
- Enrolled: 1031
- Result: At twelve months, lymphoedema 5 against 13 percent (relative risk 0.37) and sensory loss 11 against 31 percent (relative risk 0.37) after sentinel node biopsy against standard axillary treatment.
- Outcomes: Any lymphoedema at 12 months: Sentinel lymph node biopsy 5% vs Standard axillary treatment 13%; Sensory loss at 12 months: Sentinel lymph node biopsy 11% vs Standard axillary treatment 31%
- Replication: NSABP B-32 established the survival equivalence in 5,611 women; IBCSG 23-01 and AMAROS later measured the same morbidity gap when clearance was avoided in node-positive disease.

## Sources

- ALMANAC (Journal of the National Cancer Institute 2006): https://doi.org/10.1093/jnci/djj158

## Connected records

- cancers: [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [HER2-positive breast cancer](https://onco.cc/cancers/breast-her2-positive/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Triple-negative breast cancer (TNBC)](https://onco.cc/cancers/tnbc/)
- technologies: [Sentinel lymph node biopsy](https://onco.cc/technologies/sentinel-node/)
- terms: [Doing less to the armpit](https://onco.cc/terms/axillary-surgery-de-escalation/), [Lymphadenectomy (lymph node dissection)](https://onco.cc/terms/lymphadenectomy/), [Lymphoedema after breast cancer treatment](https://onco.cc/terms/breast-cancer-related-lymphoedema/), [Sentinel node biopsy](https://onco.cc/terms/sentinel-lymph-node-biopsy/)
- trials: [NSABP B-32](https://onco.cc/trials/nsabp-b32/)

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