Abstract
Accurate staging of early breast cancer requires pathological assessment of axillary lymph node involvement. We evaluated the proportion of women receiving surgery for early-stage breast cancer who do not receive any lymph node biopsy (LNB) and factors associated with not receiving LNB. Patients receiving surgery for early-stage breast cancer (T1a/T1b/T1c/T2N0) during the period 2003–2005 were selected from the National Cancer Database. Patient sociodemographic, clinical, health insurance, and facility information was collected. Logistic regression was used to assess factors predictive of not receiving LNB. The number of women meeting study inclusion criteria was 184,050, 11% of whom did not receive any LNB. Compared with White patients, Black patients had greater likelihood [odds ratio (OR) 1.10, p < 0.001] of receiving no LNB; there were no significant differences for Hispanic or other non-White patients. Individuals who were uninsured (OR 1.24, p < 0.0005) or covered by Medicare at age <65 years (OR 1.29, p < 0.0001) had greater likelihoods of no LNB compared with those with private insurance. Medicaid patients and Medicare patients ≥65 years were not significantly different from private insurance patients. Compared with the youngest quartile of patients (age ≤51 years), patients in the oldest quartile (age ≥73 years) were more than three times as likely (OR 3.30, p < 0.0001) not to receive any LNB. We conclude that, while guidelines indicate that LNB may be considered optional in certain patient groups, it remains a key component in determining stage, and thereby prognosis and appropriate treatment options. These results indicate that significant disparities exist in sampling of axillary lymph nodes among women with early-stage breast cancer.
Similar content being viewed by others
References
American Cancer Society. Cancer facts & figures 2008. Atlanta: American Cancer Society, 2008.
Cancer Care Ontario (2003). Surgical management of early-stage invasive breast cancer. Practice guideline report #1-1 version 2.2003. Available: http://www.cancercare.on.ca/pdf/pebc1-1f.pdf. Accessed 31 July 2008.
MD Anderson Cancer Center. Breast cancer—invasive. 2008. Available: http://utm-ext01a.mdacc.tmc.edu/mda/cm/CWTGuide.nsf/09ab7c4a1b0e085d86256826006ed1c5/94a2cdbf57f7a90c862563c1005dfa56/$FILE/Br%20Invasive%20V8%20Final%2002_01_08%20grp.pdf. Accessed 31 July 2008.
National Cancer Institute. Breast cancer treatment (PDQ). Stage I, II, IIIA, and operable IIIC breast cancer. 2008. Available: http://www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page7. Accessed 31 July 2008.
National Comprehensive Cancer Network. Breast cancer treatment. 2008. Available; http://www.nccn.org/patients/patient_gls/_english/_breast/5_treatment.asp. Accessed 31 July 2008.
Bland KI, Scott-Conner CE, Menck H, Winchester DP. Axillary dissection in breast-conserving surgery for stage I and II breast cancer: a National Cancer Data Base study of patterns of omission and implications for survival. J Am Coll Surg. 1999;188:586–95.
Truong PT, Bernstein V, Wai E, et al. Age-related variations in the use of axillary dissection: a survival analysis of 8038 women with T1–T2 breast cancer. Int J Radiat Oncol Biol Phys. 2002;54:795–804.
Louwman WJ, Janssen-Heijnen ML, Houterman S, Voogd AC, van der Sangen MJ, Nieuwenhuijzen GA, et al. Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based study. Eur J Cancer. 2005;41:779–85.
Gilligan MA, Kneusel RT, Hoffmann RG, Greer AL, Nattinger AB. Persistent differences in sociodemographic determinants of breast conserving treatment despite overall increased adoption. Med Care. 2002;40:181–9.
Pierce LJ, Moughan J, White J, Winchester DP, Owen J, Wilson JF. 1998–1999 patterns of care study process survey of national practice patterns using breast-conserving surgery and radiotherapy in the management of stage I-II breast cancer. Int J Radiat Oncol Biol Phys. 2005;62:183–92.
Chen AY, Halpern MT, Schrag NM, Stewart A, Leitch M, Ward E. Disparities and trends in sentinel lymph node biopsy among early-stage breast cancer patients (1998–2005). J Natl Cancer Inst. 2008;100:462–74.
Commission on Cancer. Facility Oncology Registry Data Standards manual (FORDS). Available: http://www.facs.org/cancer/coc/fords/fordsoriginal2003.pdf. Accessed 31 July 2008.
Giuliano AE, Barth AM, Spivack B, Beitsch PD, Evans SW. Incidence and predictors of axillary metastasis in T1 carcinoma of the breast. J Am Coll Surg. 1996;183:185–9.
McGee JM, Youmans R, Clingan F, Malnar K, Bellefeuille C, Berry B. The value of axillary dissection in T1a breast cancer. Am J Surg. 1996;172:501–4.
Parmigiani G, Berry DA, Winer EP, Tebaldi C, Iglehart JD, Prosnitz LR. Is axillary lymph node dissection indicated for early-stage breast cancer? A decision analysis. J Clin Oncol. 1999;17:1465–73.
Velanovich V. Axillary lymph node dissection for breast cancer: a decision analysis of T1 lesions. Ann Surg Oncol. 1998;5:131–9.
Giordano SH, Hortobagyi GN, Kau SW, Theriault RL, Bondy ML. Breast cancer treatment guidelines in older women. J Clin Oncol. 2005;23:783–91.
National Quality Forum. “Quality of Cancer Care Measures” Project Steering Committee Meeting. June 16, 2005. Available: http://www.qualityforum.org/pdf/cancer/breast.pdf. Accessed 31 July 2008.
Martelli G, Miceli R, De Palo G, et al. Is axillary lymph node dissection necessary in elderly patients with breast carcinoma who have a clinically uninvolved axilla? Cancer. 2003;97:1156–63.
Sun A, Liu FF, Pintilie M, Rawlings G. Outcome in breast cancer managed without an initial axillary lymph node dissection. Radiother Oncol. 1998;48:191–6.
Kuznetsova M, Graybill JC, Zusag TW, Hartsell WF, Griem KL. Omission of axillary lymph node dissection in early-stage breast cancer: effect on treatment outcome. Radiology. 1995;197:507–10.
Eaker S, Dickman PW, Bergkvist L, Holmberg L; Uppsala/Orebro Breast Cancer Group. Differences in management of older women influence breast cancer survival: results from a population-based database in Sweden. PLoS Med. 2006;3:e25.
Neuner JM, Gilligan MA, Sparapani R, Laud PW, Haggstrom D, Nattinger AB. Decentralization of breast cancer surgery in the United States. Cancer. 2004;101:1323–9.
Deutsch M, Flickinger JC. Patient characteristics and treatment factors affecting cosmesis following lumpectomy and breast irradiation. Am J Clin Oncol. 2003; 26:350–3.
Taylor ME, Perez CA, Halverson KJ, et al. Factors influencing cosmetic results after conservation therapy for breast cancer. Int J Radiat Oncol Biol Phys. 1995;15(31):753–64.
Mandelblatt JS, Edge SB, Meropol NJ, et al. Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care. J Clin Oncol. 2003;21:855–63.
Author information
Authors and Affiliations
Corresponding author
Additional information
A portion of this work was performed while Michael Halpern and Nicole Marlow were members of the Dept. of Health Services Research, American Cancer Society, Atlanta GA.
Rights and permissions
About this article
Cite this article
Halpern, M.T., Chen, A.Y., Marlow, N.S. et al. Disparities in Receipt of Lymph Node Biopsy Among Early-Stage Female Breast Cancer Patients. Ann Surg Oncol 16, 562–570 (2009). https://doi.org/10.1245/s10434-008-0205-7
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-008-0205-7