Annals of Surgical Oncology

, Volume 25, Issue 10, pp 3019–3029 | Cite as

The Association of Extent of Axillary Surgery and Survival in Women with N2–3 Invasive Breast Cancer

  • Tristen S. Park
  • Samantha M. Thomas
  • Laura H. Rosenberger
  • Oluwadamilola M. Fayanju
  • Jennifer K. Plichta
  • Rachel C. Blitzblau
  • Cecilia T. Ong
  • Terry Hyslop
  • E. Shelley Hwang
  • Rachel A. GreenupEmail author
Breast Oncology



Although surgical management of the axilla for breast cancer continues to evolve, axillary lymphadenectomy remains the standard of care for women with advanced nodal disease. We sought to evaluate national patterns of care in axillary surgery, and its association with overall survival (OS) among women with N2–3 invasive breast cancer.


Women (18–90 years) with clinical N2–3 invasive breast cancer who underwent axillary surgery were identified from the National Cancer Data Base (NCDB) from 2004 to 2013. Axillary surgery was categorized as sentinel lymph node biopsy (SLNB, 1–5 nodes) or axillary lymph node dissection (ALND, ≥ 10 nodes). Patient and treatment characteristics, trends over time, and overall survival (OS) were compared by surgical treatment.


Overall, 22,156 patients were identified. At diagnosis, 68.5% had cN2 and 31.5% had cN3 disease. Treatment included: lumpectomy (27%), mastectomy (73%), adjuvant chemotherapy (53.4%), neoadjuvant chemotherapy (NAC) (39.7%), radiation (74%), and endocrine therapy (54.4%). In total, 9.9% (n = 2190) underwent SLNB and 90.1% (n = 19,966) underwent ALND. Receipt of SLNB was associated with private insurance, grade 3 disease, invasive ductal cancer, NAC, and lumpectomy (all p < 0.001). After adjustment for known covariates, including chemotherapy use, ALND was associated with improved survival [hazard ratio (HR) 0.68, p < 0.001] and this effect was similar for N2 and N3 patients (axillary surgery × cN-stage interaction p = 0.29).


Axillary lymphadenectomy was associated with improved survival in patients presenting with clinical N2–3 invasive breast cancer. Further studies, particularly in the neoadjuvant setting, are needed to identify breast cancer patients with advanced nodal disease who may safely avoid a lesser extent of axillary surgery.


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Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Tristen S. Park
    • 1
  • Samantha M. Thomas
    • 2
    • 3
  • Laura H. Rosenberger
    • 3
    • 4
  • Oluwadamilola M. Fayanju
    • 3
    • 4
  • Jennifer K. Plichta
    • 3
    • 4
  • Rachel C. Blitzblau
    • 3
    • 5
  • Cecilia T. Ong
    • 4
  • Terry Hyslop
    • 2
    • 3
  • E. Shelley Hwang
    • 3
    • 4
  • Rachel A. Greenup
    • 3
    • 4
    Email author
  1. 1.Department of Surgery, Yale University Medical SchoolYale Cancer Center and Smilow Cancer HospitalNew HavenUSA
  2. 2.Department of Biostatistics and BioinformaticsDuke UniversityDurhamUSA
  3. 3.Duke Cancer InstituteDuke UniversityDurhamUSA
  4. 4.Department of SurgeryDuke University Medical CenterDurhamUSA
  5. 5.Department of Radiation OncologyDuke University Medical CenterDurhamUSA

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