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Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery.

Methods

Patients aged ≥70 years in the National Cancer Database (2004–2014) with cT1-3, cN0 breast cancer were divided into two cohorts—those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson–Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS.

Results

Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p < 0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p < 0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p < 0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61–1.70).

Conclusions

For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.

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Acknowledgment

Portions of this manuscript were presented at the 2018 Annual Meeting of the American Society of Breast Surgeons (ASBrS). The NCDB is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospitals participating in the CoC NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Funding

Dr. O. Fayanju is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award number 5KL2TR001115 (PI: Boulware). Dr. R. Greenup is supported by NIH BIRCWH K12HD043446 (PI: Andrews). 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, Durham, NC, USA

    Nina Tamirisa MD, MS, Oluwadamilola M. Fayanju MD, MA, MPHS, Rachel A. Greenup MD, MPH, Laura H. Rosenberger MD, MS, E. Shelley Hwang MD, MPH & Jennifer K. Plichta MD, MS

  2. Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA

    Samantha M. Thomas MS, Oluwadamilola M. Fayanju MD, MA, MPHS, Rachel A. Greenup MD, MPH, Laura H. Rosenberger MD, MS, Terry Hyslop PhD, E. Shelley Hwang MD, MPH & Jennifer K. Plichta MD, MS

  3. Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA

    Samantha M. Thomas MS & Terry Hyslop PhD

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  1. Nina Tamirisa MD, MS
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  3. Oluwadamilola M. Fayanju MD, MA, MPHS
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  7. E. Shelley Hwang MD, MPH
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  8. Jennifer K. Plichta MD, MS
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Corresponding author

Correspondence to Jennifer K. Plichta MD, MS.

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Disclosures

Nina Tamirisa, Samantha M. Thomas, Oluwadamilola M. Fayanju, Rachel A. Greenup, Laura H. Rosenberger, Terry Hyslop, E. Shelley Hwang, and Jennifer K. Plichta have no disclosures to declare.

Electronic supplementary material

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Supplementary material 1 (DOCX 30 kb)

Supplemental Figure 1

Patient flow diagram of inclusion and exclusion criteria (TIFF 4286 kb)

Supplemental Figure 2

Kaplan-Meier curve for unadjusted overall survival of all patients (N=133778) (TIFF 12920 kb)

Supplemental Figure 3

Kaplan-Meier curve for unadjusted overall survival of patients with cT1/cN0/cM0, grade 1/2, ER+ breast cancer by receipt of axillary lymph node surgery and pN stage (N=83797). ER: estrogen receptor. LN: lymph node (TIFF 12920 kb)

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Tamirisa, N., Thomas, S.M., Fayanju, O.M. et al. Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival. Ann Surg Oncol 25, 2890–2898 (2018). https://doi.org/10.1245/s10434-018-6595-2

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  • DOI: https://doi.org/10.1245/s10434-018-6595-2

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