Skip to main content

Advertisement

SpringerLink
Log in

Trends in Regional Nodal Management of Breast Cancer Patients with Low Nodal Burden

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

Abstract

Background

American College of Surgeons Oncology Group Z0011 confirms the safety of omitting axillary lymph node dissection (ALND) and regional nodal irradiation (RNI) in breast cancer patients with one to two positive sentinel lymph nodes (SLNs), without compromising disease-free survival (DFS) and overall survival (OS). In contrast, the NCIC MA20 trial showed improved DFS in node-positive patients undergoing ALND and RNI. We sought to examine how these data have influenced the management of patients with limited nodal burden.

Methods

Using the National Cancer Database, patients diagnosed between 2010 and 2015 and who met the criteria for Z0011 were identified. Logistic regression was used to analyze factors associated with practice patterns. The Cox proportional hazards model was used to assess the association of ALND and RNI with OS.

Results

Omission of ALND in Z0011-eligible patients reached 89.2% in 2015. This Z0011-compliant group was more likely to undergo RNI compared with the non-compliant group (36.4% vs. 31.3%; p < 0.05), with RNI increasing to 43.8% by 2015. Factors associated with the use of RNI included later year of diagnosis [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.6–2.1], hormone receptor-negative tumor (OR 1.2, 95% CI 1.1–1.4), grade 3 tumor (OR 1.2, 95% CI 1.1–1.3), treatment at a non-academic site (OR 1.2, 95% CI 1.1–1.3) and two versus one positive SLN (OR 2.0, 95% CI 1.8–2.2). With 43 months median follow-up, RNI was not associated with improved OS.

Conclusion

Since the publication of Z0011, the omission of ALND has become widespread; however nearly half of these women now receive RNI. The optimal radiation therapy approach for this low nodal burden population warrants further study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11(10):927–33.

    Article  Google Scholar 

  2. Giuliano A, McCall L, Beitsch P, et al. ACOSOG Z0011: a randomized trial of axillary node dissection in women with clinical T1–2 N0 M0 breast cancer who have a positive sentinel node. J Clin Oncol. 2010;28(18):CRA506.

    Article  Google Scholar 

  3. Giuliano AE, Ballman K, McCall L, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg. 2016;264(3):413–20.

    Article  Google Scholar 

  4. Whelan TJ, Olivotto IA, Parulekar WR, et al. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373(4):307–16.

    Article  CAS  Google Scholar 

  5. Poortmans PM, Collette S, Kirkove C, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373(4):317–27.

    Article  CAS  Google Scholar 

  6. Ong CT, Thomas SM, Blitzblau RC, et al. Patient age and tumor subtype predict the extent of axillary surgery among breast cancer patients eligible for the American College of Surgeons Oncology Group Trial Z0011. Ann Surg Oncol. 2017;24(12):3559–66.

    Article  Google Scholar 

  7. American College of Surgeons Commission on Cancer. Scope of Regional Lymph Node Surgery: A review of data validity, revised coding directives, and agency transition plans. American College of Surgeons Commission on Cancer; 2012.

  8. Black DM, Jiang J, Kuerer HM, Buchholz TA, Smith BD. Racial disparities in adoption of axillary sentinel lymph node biopsy and lymphedema risk in women with breast cancer racial disparities in sentinel lymph node biopsy racial disparities in sentinel lymph node biopsy. JAMA Surgery. 2014;149(8):788–96.

    Article  Google Scholar 

  9. Woolson RF, Clarke WR. Statistical methods for the analysis of biomedical data, vol. 371. Wiley, New York; 2011.

    Google Scholar 

  10. Hosmer D, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.

    Book  Google Scholar 

  11. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53(282):457–81.

    Article  Google Scholar 

  12. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep. 1966;50:163–70.

    CAS  PubMed  Google Scholar 

  13. Cox DR. Regression models and life‐tables. J R Stat Soc Ser B Methodol. 1972;34(2):187–202.

    Google Scholar 

  14. McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol. 2008;26(32):5213.

    Article  Google Scholar 

  15. Petrek JA, Senie RT, Peters M, Rosen PP Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001;92(6):1368–77.

    Article  CAS  Google Scholar 

  16. Giuliano AE, Ballman KV, McCall L, et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318(10):918–26.

    Article  Google Scholar 

  17. Morrow M, Jagsi R, McLeod MC, Shumway D, Katz SJ. Surgeon attitudes toward the omission of axillary dissection in early breast cancer. JAMA Oncol. 2018;4(11):1511–16.

    Article  Google Scholar 

  18. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med 2011;104(12):510–20.

    Article  Google Scholar 

  19. Mitchell KB, Lin H, Shen Y, et al. DCIS and axillary nodal evaluation: compliance with national guidelines. BMC Surg. 2017;17(1):12.

    Article  Google Scholar 

  20. Jagsi R, Chadha M, Moni J, et al. Radiation field design in the ACOSOG Z0011 (Alliance) Trial. J Clin Oncol. 2014;32(32):3600.

    Article  Google Scholar 

  21. Schlembach PJ, Buchholz TA, Ross MI, et al. Relationship of sentinel and axillary level I–II lymph nodes to tangential fields used in breast irradiation. Int J Radiat Oncol Biol Phys. 2001;51(3):671–8.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Benjamin M. Raber MD & Isabelle Bedrosian MD

  2. Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Heather Lin MS, PhD & Yu Shen BS, MS, PhD

  3. Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Simona F. Shaitelman MD

Authors
  1. Benjamin M. Raber MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Heather Lin MS, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yu Shen BS, MS, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Simona F. Shaitelman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Isabelle Bedrosian MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Isabelle Bedrosian MD.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Raber, B.M., Lin, H., Shen, Y. et al. Trends in Regional Nodal Management of Breast Cancer Patients with Low Nodal Burden. Ann Surg Oncol 26, 4346–4354 (2019). https://doi.org/10.1245/s10434-019-07901-y

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-019-07901-y

Search

Navigation