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Past
Sentinel lymph node biopsy (SLNB) has been the standard of care for clinically node-negative women with invasive breast cancer (IBC) and is also performed for women with ductal carcinoma in situ (DCIS) with high-risk features undergoing breast conservation surgery (BCS). Despite national guidelines, there is still controversy on whether to perform SLNB when the risk of metastasis is low or when it does not affect survival or locoregional control.
Present
National guidelines indicate that SLNB should not be routinely performed in women over 70 years of age with early-stage hormone receptor-positive (HR+) Her2 negative IBC1 on the basis of studies showing that axillary staging has no impact on regional control or survival2 and results in improved early quality of life.3 This study4 surveyed active members of the American Society of Breast Surgeons (ASBrS) and found that 83% recommend SLNB for a healthy 75-year-old woman with early-stage HR+ Her2 negative IBC despite these recommendations. Surgeons in academic settings were more likely to omit SLNB in this scenario. Almost half of respondents indicated that multidisciplinary teams encourage them to perform SLNB.
Similarly, one-third of ASBrS surgeons surveyed recommend SLNB for DCIS with high-risk features when guidelines advocate against it. Surgeons in academic settings were less likely to perform SLNB in this setting.
Future
Despite national guidelines, most surgeons favor SLNB in older patients with early-stage HR+ Her2 negative IBC. Clinical factors such as tumor grade, stage, and histology may be used to predict nodal positivity in this population to tailor the omission of SLNB to the subset with low-risk features.5 For DCIS undergoing BCS, one-third recommend SLNB. Academic surgeons were more likely to be practicing based on recent data. Better methods of dissemination, education, and de-implementation strategies could help decrease overtreatment in patients that do not benefit from axillary staging. In addition, respondents were greatly influenced by multidisciplinary teams, suggesting that putting forth guidelines across specialties could also improve physician adherence.
References
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Breast Cancer. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Published 2021. Accessed 2021.
Martelli G, Boracchi P, Orenti A, et al. Axillary dissection versus no axillary dissection in older T1N0 breast cancer patients: 15-year results of trial and out-trial patients. Eur J Surg Oncol. 2014;40(7):805–12.
International Breast Cancer Study G, Rudenstam CM, Zahrieh D, et al. Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10-93. J Clin Oncol. 2006;24(3):337–44.
Armani A, Douglas S, Kulkarni S, Wallace AM, Blair SL. Controversial areas in axillary staging: Are we following the guidelines? Ann Surg Oncol. 2021. https://doi.org/10.1245/s10434-021-10443-x.
Welsh JL, Hoskin TL, Day CN, Habermann EB, Goetz MP, Boughey JC. Predicting nodal positivity in women 70 years of age and older with hormone receptor-positive breast cancer to aid incorporation of a Society of Surgical Oncology Choosing Wisely guideline into clinical practice. Ann Surg Oncol. 2017;24(10):2881–8.
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Armani, A., Douglas, S., Kulkarni, S. et al. ASO Author Reflections: Do Surgeon Practice Patterns Follow National Guidelines for Axillary Staging?. Ann Surg Oncol 29 (Suppl 3), 551–552 (2022). https://doi.org/10.1245/s10434-021-10601-1
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DOI: https://doi.org/10.1245/s10434-021-10601-1