Original Scientific Articles
Axillary dissection in breast-conserving surgery for stage i and ii breast cancer: a national cancer data base study of patterns of omission and implications for survival1

Presented at the American College of Surgeons 84th Annual Clinical Congress, Orlando, FL, October 1998.
https://doi.org/10.1016/S1072-7515(99)00056-3Get rights and content

Abstract

Background: Breast conservation (partial mastectomy, axillary node dissection or sampling, and radiotherapy) is the current standard of care for eligible patients with Stages I and II breast cancer. Because axillary node dissection (AND) has a low yield, some have argued for its omission. The present study was undertaken to determine factors that correlated with omission of AND, and the impact of the decision to omit AND on 10-year relative survival.

Study Design: A retrospective review of National Cancer Data Base (NCDB) data for 547,847 women with Stage I and Stage II breast cancer treated in US hospitals from 1985 to 1995 was undertaken. A subset of 47,944 Stage I and 23,283 Stage II women treated with breast-conserving surgery (BCS) was identified. Cross-tab analysis was used to compare patterns of surgical care within this subset. Relative survival was calculated as the ratio of observed survival to the expected survival for women of the same age and racial/ethnic background.

Results: The rate of BCS with and without AND increased steadily from 17.6% and 6.4% of patients from 1985–1989, to 36.6% and 10.6% of patients from 1993–1995 respectively. AND was more likely to be omitted in women with Stage I than women with Stage II disease (14.5% versus 5.5%). Similarly, AND was omitted more frequently in women with Grade 1 than women with higher grades (Grade 1, 14.9%; Grade 2, 10.1%; Grade 3, 7.1%; Grade 4, 7%). Although the rate of BCS with AND varied considerably according to location in the breast, the overall rate of BCS without AND appeared independent of site of lesion. Women over the age of 70 years were more than twice as likely to have AND omitted from BCS than their younger counterparts. Women with lower incomes, women treated in the Northeast, or at hospitals with annual caseloads < 150 were all less likely to undergo AND than their corresponding counterparts. Ten-year relative survival for Stage I women treated with partial mastectomy and AND was 85% (n = 1242) versus 66% (n = 1684) for comparable women in whom AND was omitted. BCS with AND followed by radiation therapy for Stage I disease resulted in 94% (n = 5469) 10-year relative survival, compared with 85% (n = 1284) without AND. Addition of both radiation and chemotherapy to BCS with AND for Stage I disease resulted in 86% (n = 2800) versus 58% (n = 512) without AND. In contrast, Stage II women treated with BCS with AND followed by radiation and chemotherapy experienced a 72% 10-year relative survival.

Conclusions: A significant number of women with Stage I breast cancer do not undergo AND as part of BCS. The trend is most pronounced for the elderly, but significant fractions of women of all ages are also being undertreated by current standards. Ten-year survival is significantly worse when AND is omitted. This adverse survival effect is not solely from understaging.

Section snippets

Methods

The National Cancer Data Base is a joint resource maintained by the American College of Surgeons and the American Cancer Society. Its primary goal is to lower the morbidity and mortality of cancer by compiling and analyzing data about cancer management and outcomes. The methods of the NCDB have been described previously.4 The American Cancer Society and the American College of Surgeons provide core support for the NCDB. The total cost associated with maintaining this national resource cannot be

Results

There was a trend toward increasing use of BCS, both with and without AND, over the 3 time periods encompassed within the study, and a decreased reliance on modified radical mastectomy (Table 1). A trend toward increased use of multimodality therapy, rather than surgery alone, was noted over time (Table 2).

Discussion

The first effective treatment for breast cancer was surgical. Radical mastectomy with extensive regional lymphadenectomy served to control local disease at a time when early detection was not possible and no other treatment modalities were available. This cosmetically mutilating operation was associated with an incidence of lymphedema approaching 40%.7 Molecular biologic techniques were unknown. Clinical and pathologic observations were the only tools available to predict tumor behavior. Cancer

References (26)

  • R.G Margolese

    Axillary surgery in breast cancer—there still is a debate

    Eur J Cancer

    (1993)
  • P.A Cabanes et al.

    Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer

    Lancet

    (1992)
  • J.R Harris et al.

    Patients with early breast cancer benefit from effective axillary treatment

    Breast Cancer Res Treat

    (1985)
  • B Fisher et al.

    Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer

    New Engl J Med

    (1985)
  • D.J Winchester et al.

    The National Cancer Data Base Report on the results of a large nonrandomized comparison of breast preservation and modified radical mastectomy

    Cancer

    (1997)
  • K.I Bland et al.

    The National Cancer Data Base 10-Year Survey of Breast Carcinoma Treatment at Hospitals in the United States

    Cancer

    (1998)
  • D.P Winchester et al.

    The National Cancer Data Base Report on breast carcinoma characteristics and outcome in relation to age

    Cancer

    (1996)
  • E Shambaugh et al.

    Statistics and Epidemiology for Cancer Registrars, Self-instructional Manual for Cancer Registrars, Book 7. Surveillance Epidemiology and End Results Program

    (1995)
  • D.S Reintgen et al.

    Lymphedema in the postmastectomy patientpathophysiology, prevention, and management

  • B Fisher et al.

    Comparison of radical mastectomy with alternative treatments for primary breast cancera first report of results from a prospective randomized clinical trial

    Cancer

    (1977)
  • E Busch et al.

    Patterns of breast cancer care in the elderly

    Cancer

    (1996)
  • J.M Samet et al.

    Determinants of receiving breast-conserving surgery. The Surveillance, Epidemiology, and End Results Program, 1983–1986

    Cancer

    (1994)
  • D.A Lazavich et al.

    Underutilization of breast-conserving surgery and radiation therapy among women with stage I or II breast cancer

    JAMA

    (1991)
  • Cited by (117)

    • Surgical Oncology and Geriatric Patients

      2019, Clinics in Geriatric Medicine
      Citation Excerpt :

      If however, the SLNB proves the presence of axillary disease, the management is still controversial; recent studies have favored conservative operative approaches in the elderly in order to reduce postoperative complications. Studies using the National Cancer Database have found that axillary lymph node dissection (ALND) is routinely omitted in patients older than 80 years.15 Based on the ACS Oncology Group Z0011 trial,16 patients with T1-2N0M0 breast cancer undergoing breast-conserving surgery and adjuvant whole-breast radiotherapy who were found to have 1 to 2 positive SLNs can forgo completion ALND.

    • Principles of Surgical Oncology in the Elderly

      2012, Clinics in Geriatric Medicine
      Citation Excerpt :

      The true value of ALND in clinically N0 elderly patients is nevertheless obscure; a recent study from Milan by Martelli and colleagues60 showed no advantage, confirming the findings of the ACOSOG Z011 trial, where the omission of ALND did not impact on local recurrence, distant recurrence, or overall survival in older patient cohorts. A further influencing factor away from more routine ALND is the presumption that older patients have a higher rate of postoperative lymphoedema,61 although this too is controversial; Bland and co-workers56 showed in a large patient cohort (84,877 women treated for stage I breast cancer) that in every clinical scenario involving breast-conserving surgery where ALND was omitted, there was a significantly lower rate of survival and that the addition of systemic therapy did not overcome the adverse effect of ALND omission. There does not seem to be any advantage for ALND in early T1N0 tumors in older patients for overall mortality, breast cancer-specific mortality, or the crude cumulative incidence of breast events (including local recurrence or metachronous cancer), where the incidence of axillary recurrence appears to be very low if a full ALND is not performed62,63 and where sentinel lymph node biopsy in the elderly has been shown to be just as effective as in younger patient cohorts.64

    • Early primary breast cancer in the elderly - Pattern of presentation and treatment

      2011, Surgical Oncology
      Citation Excerpt :

      This finding contrasts with the previous studies which have found that elderly patients are less likely to be offered and therefore receive breast-conserving surgery [13]. They were also less likely to have axillary surgery when compared to younger patients [8, 12, 22]. The lack of axillary surgery could impact on the accuracy of the staging of the cancer and limit the prognostic information, subsequently decreasing the treatment options available to them [8].

    • Predictors of persistent pain after breast cancer surgery: A systematic review and meta-analysis of observational studies

      2016, CMAJ
      Citation Excerpt :

      Women who underwent axillary lymph node dissection experienced a 21% increase in the absolute risk of chronic postoperative pain. Although axillary staging is associated with persistent pain, the risks of omitting axillary nodal sampling include increasing the number of patients who are understaged and undertreated and who experience reduced survival.65 Thus, omission of axillary staging is not an appropriate approach to modifying pain risk.

    View all citing articles on Scopus
    1

    No competing interests declared.

    View full text