Axillary lymph node evaluation is performed frequently in women with ductal carcinoma in situ (DCIS) breast cancer, despite recommendations generally against such an assessment procedure in women with localized cancer undergoing breast-conserving surgery (BCS). These findings were published by JAMA Oncology (2015; doi:10.1001/jamaoncol.2015.0389).
Axillary lymph node evaluation is the standard of care in the surgical management of invasive breast cancer; however, a benefit has not been demonstrated in patients with DCIS. For women with invasive breast cancer, sentinel lymph node biopsy (SLNB) replaced full axillary lymph node dissection (ALND). The sentinel nodes are the first few lymph nodes into which a tumor drains.
Guidelines published by the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) recommend against axillary evaluation in women undergoing BCS. If invasive cancer were to be discovered, SLNB could be performed at a later date. But because a total mastectomy precludes future SLNB, the guidelines suggest SLNB may be appropriate for some high-risk patients because axillary evaluation would be indicated if invasive cancer was found, according to background in the study.
Dawn L. Hershman, MD, MS, of Columbia University Medical Center, New York, and coauthors determined the incidence of axillary lymph node evaluation in women with DCIS and identified factors associated with the procedure. The authors analyzed medical records from 2006 through 2012 for women with DCIS who underwent BCS or mastectomy. The study analysis included 35,591 women.
Of the women with DCIS, 26,580 (74.7%) underwent BCS and 9,011 (25.3%) underwent mastectomy. The authors found that 17.7% of the women who had BCS and 63% of those patients who underwent mastectomy had an axillary lymph node evaluation, according to the results.
Among the women who underwent a mastectomy and axillary evaluation, full ALND was performed in 15.2%, and SLNB was performed in 47.8%. Among the women who underwent BCS with axillary evaluation, SLNB was performed in 16.7%, and ALND was performed in only 1% of those patients.
Rates of axillary evaluation increased over time with mastectomy from 56.6% in 2006 to 67.4% in 2012, but the rates remained relatively stable with BCS, with 18.5% in 2006 and 16.2% in 2012.
Factors such as having surgery at a nonteaching hospital in an urban area were associated with higher rates of axillary evaluation with mastectomy, and increasing surgeon volume was associated with decreasing axillary evaluation among women undergoing BCS.
“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,” stated the authors. “Perhaps most importantly, additional prospective evaluation is needed to determine if there is a clinical benefit to axillary evaluation in women with DCIS.”