Evaluation of: Dings PJ, Elferink MA, Strobbe LJ, de Wilt JH. The prognostic value of lymph node ratio in node-positive breast cancer: a Dutch nationwide population-based study. Ann. Surg. Oncol. 20(8), 2607–2614 (2013). Breast cancer (BC) is the most common cancer in women worldwide and affects one in eight women in the UK at some point in their lifetime. Advances in treatment have led to greatly improved survival rates. Management of axillary lymph node (LN) metastases has been a controversial but evolving area of BC therapy. Positive LN status is of vital importance in determining long-term outcomes. Recent studies have shown that it is not only the absolute number of involved LNs, but also the ratio of metastatic to examined LNs (or LN ratio [LNR]) that confers prognostic information. In the evaluated article, a population-wide study was performed to elucidate the influence of LNR on mortality risk in Dutch BC patients. LNR was an independent prognostic factor, but was not better than current tumor, node, metastasis pathological nodal staging. It was, however, able to discriminate subpopulations within pathological nodal categories. In this article we examine the use of LNR in BC.