The assessment of axillary lymph node metastasis in early-stage breast cancer is crucial for disease staging, adjuvant treatment decision-making, regional control, and prognosis estimation. However, the approach to axillary management has shown a "de-escalation" trend. For clinically node-negative (cN0) early-stage breast cancer, sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as the standard procedure for axillary staging. If sentinel lymph nodes are negative, patients can forgo ALND. Even in cases of low-burden sentinel lymph node metastasis, ALND may be omitted with effective systemic therapy and regional radiotherapy. Some cN0 early-stage breast cancer patients may qualify to avoid axillary surgery altogether, but patient selection requires greater precision. For patients with clinically node-positive (cN1) early-stage breast cancer, neoadjuvant therapy can downstage them to cN0, allowing SLNB to replace ALND. Preliminary data on false negatives and safety are available, but many issues with SLNB post-neoadjuvant therapy remain unresolved, requiring further clinical research. In the future, with the advancement and application of functional imaging and predictive models, assessments of oncologic characteristics, metastatic burden, and treatment response in early-stage breast cancer will become more accurate. Axillary management for early-stage breast cancer will become more precise, and de-escalation will be safer.