Annals of Surgical Oncology

, Volume 23, Issue 10, pp 3354–3364 | Cite as

A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer

  • Miriam W. Tsao
  • Sylvie D. Cornacchi
  • Nicole Hodgson
  • Marko Simunovic
  • Lehana Thabane
  • Ji Cheng
  • Mary Ann O’Brien
  • Barbara Strang
  • Som D. Mukherjee
  • Peter J. Lovrics
Breast Oncology



Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates.


Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009–August 2010); TP2, after publication of Z0011 (March 2011–June 2012); and TP3, after guideline dissemination (January 2013–April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. ≤50 years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age > 50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs).


The SLNB rate increased from 56 % (n = 620), to 70 % (n = 774), to 78 % (n = 844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71 %; TP2, 43 %; TP3, 17 %) [p < 0.001]. The cALND rate also decreased over time among cases recommended to have cALND using the guideline criteria (TP1, 92 %; TP2, 69 %; TP3, 58 %) [p < 0.001]. Based on multivariable analysis, age and nodal factors appeared to be significant factors for cALND decision making.


Publication of ACOSOG Z0011 and regional guideline dissemination were associated with a marked decrease in cALND after +SLNB, even among several cases in which the guideline recommended cALND.


Breast Cancer Sentinel Lymph Node Biopsy Axillary Lymph Node Dissection Lymph Node Ratio Positive Sentinel Lymph Node 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors would like to thank Dyda Dao, Dominika Bhatia, and Olivia Lovrics for their assistance with data collection and management.


Funding was provided by the Hamilton Academic Health Sciences Organization (HAHSO) Innovation Grant, and by funds from the Department of Surgery, McMaster University and the McMaster Buffet Taylor Breast Cancer Research Chair, Department of Oncology, McMaster University. The funding sources played no role in the design, conduct, or reporting of this study.


Miriam W. Tsao, Sylvie D. Cornacchi, Nicole Hodgson, Marko Simunovic, Lehana Thabane, Ji Cheng, Mary Ann O’Brien, Barbara Strang, Som D. Mukherjee, and Peter J. Lovrics have no conflicts of interest to disclose.


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Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Miriam W. Tsao
    • 1
  • Sylvie D. Cornacchi
    • 1
  • Nicole Hodgson
    • 1
    • 2
  • Marko Simunovic
    • 1
    • 2
    • 3
  • Lehana Thabane
    • 3
    • 4
  • Ji Cheng
    • 4
  • Mary Ann O’Brien
    • 5
  • Barbara Strang
    • 6
  • Som D. Mukherjee
    • 6
  • Peter J. Lovrics
    • 1
    • 2
    • 7
  1. 1.Department of SurgeryMcMaster UniversityHamiltonCanada
  2. 2.Department of Surgical OncologyHamilton Health Sciences and Juravinski Hospital and Cancer CentreHamiltonCanada
  3. 3.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  4. 4.Biostatistics UnitSt. Joseph’s HealthcareHamiltonCanada
  5. 5.Department of Family and Community MedicineUniversity of TorontoTorontoCanada
  6. 6.Department of OncologyMcMaster UniversityHamiltonCanada
  7. 7.Department of SurgerySt. Joseph’s HealthcareHamiltonCanada

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