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Axillary node evaluation common in DCIS, despite uncertain benefits
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Women with surgically treated ductal carcinoma in situ, or DCIS, regularly underwent axillary lymph node evaluation, despite guidelines recommending against its use in this setting, according to study results.
Axillary lymph node evaluation — with either sentinel lymph node biopsy (SLNB) or full axillary lymph node dissection — also was associated with surgeon volume and facility type, results showed.
“The surgical treatment options of mastectomy and breast-conserving surgery are similar for women with invasive cancer and DCIS,” Dawn L. Hershman, MD, MS, of the Columbia University Medical Center, and colleagues wrote. “However, while lymph node evaluation is standard for women with invasive cancer, there is no demonstrated benefit for lymph node assessment for women with DCIS.”
Dawn L. Hershman
Hershman and colleagues evaluated the medical records of 35,591 women with DCIS who underwent breast-conserving surgery (74.7%) or mastectomy (25.3%) between 2006 and 2012. The mean age of women at the time of surgery was 59.8 years (range, 18-90) and 71.1% were white.
Researchers evaluated whether patients underwent an axillary lymph node evaluation and evaluated its use with regard to patients’ age, race, marital status and insurance status.
Seventy percent women with DCIS (n = 25,205) did not undergo axillary lymph node evaluation. However, 29.2% (n = 10,386) of the women did undergo an evaluation, most of whom underwent SLNB (84.2% n = 8,742).
More women who underwent mastectomy received an axillary evaluation compared with women who underwent breast-conserving surgery (63% vs. 17.7%).
The rate of axillary lymph node evaluation increased steadily between 2006 and 2012 for women undergoing mastectomy (56.6% to 67.4%) but remained relatively stable in women undergoing breast-conserving surgery (18.5% to 16.2%). SLNB was the most frequently performed surgical evaluation in both groups, whereas the use of axillary lymph node dissection decreased during that time for women who underwent mastectomy (20% to 10.7%) and breast-conserving surgery (1.2% to 0.3%).
Overall, axillary node evaluation was more common among women treated at nonteaching hospitals (RR = 1.13; 95% CI, 1.06-1.21) and in an urban location (RR = 1.3; 95% CI, 1.09-1.55).
Hospital and surgeon factors had a greater effect on the use of surgical axillary evaluation in women receiving breast-conserving surgery. In this cohort, axillary lymph node evaluation also occurred more frequently at nonteaching hospitals (RR = 1.17; 95% CI, 1.03-1.33), and among Hispanic women, although this association did not reach statistical significance (RR = 1.32; 95% CI, 1-1.74). High-volume surgeons were less likely to perform axillary lymph node evaluation in these women than low-volume surgeons (RR = 0.54; 95% CI, 0.45-0.64).
The researchers acknowledged limitations of their study, including a higher sample of women treated at small, mid-sized, nonteaching and urban hospitals. Surgical decision-making factors such as size, grade and location of DCIS were unavailable, and surgeon volume could not be completely confirmed due to a lack of available linkage of surgeon data across hospitals.
“Though use of axillary evaluation in DCIS may be appropriate in some cases, the high rates of axillary evaluation indicate that additional research is needed in this area,” Hershman and colleagues concluded. “In addition to better predictive tools for axillary involvement, other surgical approaches should be evaluated, such as placing a marker in the node rather than removing it, thus allowing for sentinel node removal at a second operation should invasive cancer be identified on final pathology. Perhaps most importantly, additional prospective evaluation is needed to determine if there is a clinical benefit to axillary evaluation in women with DCIS.”
These data do not address the fact that guidelines recommend axillary node evaluation in some women with DCIS, Kimberly J. Van Zee, MD, MS, of the department of surgery at Memorial Sloan Kettering Cancer Center, wrote in an accompanying editorial.
“Guidelines do recommend performing a SLNB if suspicion for invasive cancer is high (for example, presentation as a mass on examination or mammogram),” Van Zee wrote. “It would be helpful to understand what proportion of the 17% of women undergoing breast-conserving surgery and SLNB had such a presentation. It is possible that a significant proportion of women with a presentation suggestive of invasion were saved a second operation because invasion was found but a SLNB had already been performed at the first operation. For women in whom the suspicion of invasion is high, the morbidity and extra expense of doing the SLNB at the time of breast-conserving surgery must be balanced against that of a second operative procedure if invasive cancer is found.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures.
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