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Extent of axillary surgery in inflammatory breast cancer: a survival analysis of 3500 patients

  • Epidemiology
  • Published:
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Abstract

Purpose

Inflammatory breast cancer (IBC) is an aggressive variant for which axillary lymph node (LN) dissection following neoadjuvant chemotherapy (NACT) remains standard of care. But with increasingly effective systemic therapy, it is unclear whether more limited axillary surgery may be appropriate in some IBC patients. We sought to examine whether extent of axillary LN surgery was associated with overall survival (OS) for IBC.

Methods

Female breast cancer patients with non-metastatic IBC (cT4d) diagnosed 2010–2014 were identified in the National Cancer Data Base. Cox proportional hazards modeling was used to estimate the association between extent of axillary surgery (≤ 9 vs ≥ 10 LNs removed) and OS after adjusting for covariates, including post-NACT nodal status (ypN0 vs ypN1-3) and radiotherapy receipt (yes/no).

Results

3471 patients were included: 597 (17.2%) had cN0 disease, 1833 (52.8%) had cN1 disease, and 1041 (30%) had cN2-3 disease. 49.9% of cN0 patients were confirmed to be ypN0 on post-NACT surgical pathology. Being ypN0 (vs ypN1-3) was associated with improved adjusted OS for all patients. Radiotherapy was associated with improved adjusted OS for cN1 and cN2-3 patients but not for cN0 patients. Regardless of ypN status, there was a trend towards improved adjusted OS with having ≥ 10 (vs ≤ 9) LNs removed for cN2-3 patients (HR 0.78, 95% CI 0.60–1.01, p = 0.06) but not for cN0 patients (p = 0.83).

Conclusions

A majority of IBC patients in our study presented with node-positive disease, and for those presenting with cN2-3 disease, more extensive axillary surgery is potentially associated with improved survival. For cN0 patients, however, more extensive axillary surgery was not associated with a survival benefit, suggesting an opportunity for more personalized care.

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Data availability

The data that support the findings of this study are available from the National Cancer Data Base (NCDB) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of the NCDB.

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Funding

Dr. Fayanju is currently supported by the National Institutes of Health (NIH) under Award Number 1K08CA241390 (PI: Fayanju) and previously by the National Center for Advancing Translational Sciences (NCATS) of the NIH under Award Number 1KL2TR002554 (PI: Svetkey). Dr. Greenup is supported by the NIH BIRCWH K12HD043446 (PI: Andrews). Dr. Suneja is supported by grants K08CA228631 (PI: Suneja) and P30AI064518 (PI: Weinhold) from the NIH. Dr. Devi is supported by grants from the Department of Defense (DoD) W81XWH-17–1-0297 (PI: Devi) and the IBC Network Foundation (PI: Devi). This work is also supported by the Duke Cancer Institute through NIH grant P30CA014236 (PI: Kastan). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Authors and Affiliations

  1. Department of Surgery, Duke University Medical Center, Box 3513, Durham, NC, 27710, USA

    Oluwadamilola M. Fayanju, Rachel A. Greenup, Jennifer K. Plichta, Laura H. Rosenberger, Gayathri R. Devi & E. Shelley Hwang

  2. Women’s Cancer Program, Duke Cancer Institute, Durham, NC, 27710, USA

    Oluwadamilola M. Fayanju, Rachel A. Greenup, Jennifer K. Plichta, Laura H. Rosenberger, Jeremy Force, Gita Suneja, Gayathri R. Devi & E. Shelley Hwang

  3. Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA

    Oluwadamilola M. Fayanju & Rachel A. Greenup

  4. Duke Forge, Duke University, Durham, NC, 27710, USA

    Oluwadamilola M. Fayanju

  5. Department of Surgery, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA

    Oluwadamilola M. Fayanju

  6. Biostatistics Shared Resource, Duke Cancer Institute, Durham, NC, 27710, USA

    Yi Ren & Terry Hyslop

  7. Department of Medicine, Duke University Medical Center, Box 3893, Durham, NC, 27710, USA

    Jeremy Force

  8. Department of Radiation Oncology, Duke University School of Medicine, Box 3085, Durham, NC, 27710, USA

    Gita Suneja

  9. Duke Global Health Institute, Durham, NC, 27710, USA

    Gita Suneja

  10. Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, 02115, USA

    Tari A. King & Faina Nakhlis

  11. Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, 02115, USA

    Tari A. King & Faina Nakhlis

  12. Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Box 2717, Durham, NC, 27710, USA

    Terry Hyslop

Authors
  1. Oluwadamilola M. Fayanju
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  2. Yi Ren
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  3. Rachel A. Greenup
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  4. Jennifer K. Plichta
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  5. Laura H. Rosenberger
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  6. Jeremy Force
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  7. Gita Suneja
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  8. Gayathri R. Devi
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  9. Tari A. King
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  10. Faina Nakhlis
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  11. Terry Hyslop
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  12. E. Shelley Hwang
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Corresponding author

Correspondence to Oluwadamilola M. Fayanju.

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Conflict of interest

Dr. Force is a consultant for Genomic Health, Nanostring, and Pfizer, Dr. King is a consultant for Genomic Health, Dr. Hyslop is a consultant for AbbVie, and Dr. Fayanju, Mr. Ren, Dr. Greenup, Dr. Plichta, Dr. Rosenberger, Dr. Suneja, Dr. Devi, Dr. Nakhlis, and Dr. Hwang have no conflicts of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with human participants or animals performed by any of the authors as de-identified data were used and the study was granted exempt status by our institutional review board.

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Fayanju, O.M., Ren, Y., Greenup, R.A. et al. Extent of axillary surgery in inflammatory breast cancer: a survival analysis of 3500 patients. Breast Cancer Res Treat 180, 207–217 (2020). https://doi.org/10.1007/s10549-020-05529-1

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  • DOI: https://doi.org/10.1007/s10549-020-05529-1

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