Clear lymph nodes do not always mean low risk, Singapore breast cancer study finds

• Real-world data from 2,987 Singapore patients provides new insights into long-term outcomes after early breast cancer diagnosis and treatment
• Around one in six higher-risk patients without lymph-node spread experienced recurrence or death within seven years, comparable to patients whose cancer had spread to one to three lymph nodes, showing that clear lymph nodes do not always mean low risk
• Findings reinforce the importance of early conversations with patients about their risk of recurrence and treatment options

SINGAPORE, 29 October 2026 – For many women with early breast cancer, being told that the cancer has not spread to the lymph nodes comes as a relief. However, a new Singapore study shows that this is not always the full picture. Around one in six (16.7%) patients whose cancer had not spread to the lymph nodes, but whose tumours had other features linked to a higher chance of recurrence, experienced recurrence or death within seven years. Their outcomes were comparable to those of patients whose cancer had spread to one to three lymph nodes, showing that clear lymph nodes alone do not always mean low risk.

Presented at the European Society for Medical Oncology Congress (ESMO 2026) in Madrid from 23 to 27 October, the Real-World Assessment of Treatment Patterns and Outcomes During the Pre-Adjuvant CDK4/6 Inhibitor Era of HR+/HER2− Early Breast Cancer in Singapore (RACES) study was conducted through a research collaboration between Novartis Singapore and the National Cancer Centre Singapore (NCCS) ¹. The study analysed real-world data from 2,987 patients with hormone receptor-positive (HR+), HER2-negative (HER2−) early breast cancer in Singapore’s Joint Breast Cancer Registry, with a median follow-up of more than eight years. HR+/HER2− is the most common subtype of breast cancer, accounting for around 70% of cases².

Seven years after diagnosis, 16.7% of higher-risk patients whose cancer had not spread to the lymph nodes had experienced recurrence or death. This was almost the same as the 16.4% seen in patients whose cancer had spread to one to three lymph nodes. Among lower-risk patients whose cancer had not spread to the lymph nodes, the figure was 9.4%. The findings suggest that lymph-node status alone does not show a patient's full risk of recurrence, and that doctors should discuss risk and treatment options with patients early.

“Being told that your lymph nodes are clear is good news, but it should not be where the conversation about risk ends. “Breast cancer has a particularly significant impact on East Asian women, who tend to be diagnosed a decade earlier than their Caucasian counterparts³, often when they are balancing multiple roles with careers, child-raising and responsibilities caring for ageing parents. RACES’ findings reinforce the need to look beyond lymph-node involvement when assessing recurrence risk, so that clinicians have early conversations with patients about their individual risk and discuss available treatment options to enable them to make informed care decisions,” said Dr Elaine Lim, the study’s Principal Investigator and lead author, and Senior Consultant, Division of Medical Oncology at the National Cancer Centre Singapore.

RACES’ findings also highlight the potential role of Ki67, a marker measured through a test on tumour tissue that shows how quickly cancer cells are dividing, giving doctors a sense of how aggressive the cancer may be. As Ki67 testing costs less than genomic testing, the researchers suggest that making it part of routine care may help identify patients with node-negative early breast cancer and at higher risk of recurrence, supporting early and more informed discussions about treatment after surgery. As Ki67 testing was not routinely performed during the study period, further work is needed to confirm its role.

Study co-lead and co-author Dr Esdy Rozali, Novartis Singapore Medical Affairs, said: “Behind every number in RACES is a woman in Singapore wondering whether her cancer will come back. Its long-term data can help clinicians look beyond nodal status, identify higher-risk patients more comprehensively and support earlier, more informed conversations about recurrence risk and treatment after surgery.”

Beyond the clinic, Novartis Singapore works with patient organisations to help women understand and talk about their risk of recurrence. Through Know More, Fear Less, an initiative started by Novartis and shaped together with the Breast Cancer Foundation and Singapore Cancer Society, patients and survivors can find resources, informed by survivors’ own experiences, to help them better understand their risk, prepare questions for their doctors and seek support after treatment.

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About the RACES Study

The Real World Assessment of treatment patterns and outcomes during the pre-adjuvant CDK4/6 inhibitor era of HR+/HER2− Early Breast Cancer in Singapore (RACES) study is a retrospective analysis of 2,987 patients with HR+/HER2− early breast cancer (stage I–III, all treated with curative surgery) from the Joint Breast Cancer Registry who were diagnosed between 2010 and 2017. With a median follow-up of 97.3 months (just over eight years), the study examined patient characteristics, treatment patterns and long-term outcomes before adjuvant CDK4/6 inhibitors were introduced. The RACES study is a research collaboration between NCCS and Novartis Singapore, with NCCS as the regulatory sponsor and funding from Novartis. Access the full study here

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