Researchers from Columbia University Medical Center (NY, USA) have discovered that despite recommendations against such a procedure, axillary lymph node evaluation is regularly performed in women diagnosed with ductal carcinoma in situ (DCIS). This research was published recently in JAMA Oncology.
Guidelines published by the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend against axillary evaluation in women undergoing breast-conserving surgery (BCS). The procedure – despite being the standard of care in the surgical management of invasive breast cancer – has not demonstrated benefit in DCIS.
In order to determine the incidence of axillary lymph node evaluation in women with DCIS and identify the associated factors, the Columbia team analyzed medical records from 2006–2012 and identified 35,591 women with DCIS who had undergone either BCS or mastectomy.
The results reported that 74.7% of the women diagnosed with DCIS (26,580) had BCS and 25.3% (9011) underwent a mastectomy. It was also reported that 17.7% of the women who had BCS and 63% of those who underwent mastectomy had an axillary lymph node evaluation. The proportion of patients undergoing this procedure increased over time with mastectomy, from 56.6% in 2006 to 67.4% in 2012, however the rates remained relatively consistent with BCS.
In patients with invasive breast cancer, sentinel lymph node biopsy replaced full axillary lymph node dissection (ALND) as the standard of care. The results from this study demonstrated that out of the 63% of women who had a mastectomy and axillary evaluation, 15.2% of those had full ALND and 47.8% had sentinel lymph node biopsy. Among the 17.7% who had axillary evaluation with BCS, 16.7% underwent SLNB, with only 1% undergoing ALND.
Speaking to Oncology Central, author Dawn L Hershman of Columbia University commented: “There are areas in cancer care where we know that there is overdiagnosis and overtreatment, and that understanding these areas may help us reduce cost and improve outcomes. If we learn that there is no added benefit to evaluating lymph nodes in patients with DCIS we may be able to save many patients from having this procedure.”
The results also indicate that factors such as undergoing surgery at a nonteaching hospital in an urban area were associated with higher rates of axillary evaluation with mastectomy. Increasing the surgeon volume was found to be associated with decreasing axillary evaluation among women undergoing BCS.
Hershman concludes: “The data…may change some practice patterns and it might stimulate research in the area to understand the benefits of these procedures in women with DCIS. One would hope that the use of sentinel lymph node would decrease in patients with DCIS who are undergoing lumpectomy.”
Sources: Coromilas E J, Wright J D, Huang Y et al. The Influence of Hospital and Surgeon Factors on the Prevalence of Axillary Lymph Node Evaluation in Ductal Carcinoma In Situ; JAMA Oncology doi: 10.1001/jamaoncol.2015.0389 (2015); JAMA Oncology press release