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Some Breast Cancer Patients Derive No Benefit from Nodal Dissection

National Cancer Data Base analysis finds that women with microscopic lymph node metastases detected on sentinel lymph node biopsy may not need a completion nodal dissection

NEWS FROM THE AMERICAN COLLEGE OF SURGEONS | FOR IMMEDIATE RELEASE

CHICAGO (May 7, 2009): A recent observational study of 97,000 women with breast cancer and nodal metastases indicates that there is no appreciable difference in axillary recurrence and survival between those who undergo sentinel lymph node (SLN) biopsy alone versus SLN biopsy with the more invasive completion axillary lymph node dissection (ALND). This new analysis from the National Cancer Data Base (NCDB) of the American College of Surgeons (ACS) was recently published online in the Journal of Clinical Oncologyand will appear in a print version of the journal within the next few weeks. The study’s authors analyzed data from approximately 1,400 hospitals. These women with breast cancer underwent SLN biopsy for clinically node-negative breast cancer from 1998 to 2005 and were found to have nodal metastases. The authors found that some patients with lymph node metastases identified on sentinel node biopsy may not need to have the rest of their lymph nodes removed.

“In certain patients, particularly those with microscopic nodal metastases, one may not need to perform a completion axillary lymph node dissection. However in patients with more tumor burden in their lymph nodes—with macroscopic disease—completion ALND may provide a small benefit and potentially result in better outcomes,” according to lead author Karl Bilimoria, MD, MS, who was an American College of Surgeons (ACS) Research Fellow at the time the analysis was performed, and is a surgical resident at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Despite these findings, many women with axillary nodal involvement confirmed via SLN biopsy still undergo completion ALND, cautioned coauthor David J. Winchester, MD, FACS, of Northwestern University Medical School. “The average physician out there may be overusing axillary lymph node dissection in many patients,” Dr. Winchester explained. “We have relied upon that operation too much, and this paper points out we may not need to do it in terms of a survival difference or a regional recurrence difference. This is an operation associated with significant morbidity.” Among the morbidities linked to ALND are a lifetime risk of lymphedema, problematic cosmetic outcomes, longer recovery times and more postoperative pain than SLN biopsy alone. The researchers detected a shift in practice patterns that made sense in light of their findings. “For microscopic nodal disease from 1998 to 2005, the proportion of patients undergoing SLN biopsy alone without a completion nodal dissection increased considerably, from about 25 percent to 45 percent, whereas for patients with more substantial nodal metastases, the macroscopic group, the proportion stayed fairly constant over the time course of the study,” Dr. Bilimoria said. “This shift in practice patterns makes sense as physicians may have anecdotally found that completion nodal dissection is not necessary in all patients.” The study findings along with conclusions from small institutional series and previous clinical trials can be interpreted together and potentially change how physicians counsel their patients. “These data allow clinicians to have a discussion with their patients, especially those with microscopic nodal metastases, whether a completion axillary lymph node dissection would be beneficial,” Dr. Bilimoria concluded.

In addition to Drs. Bilimoria and Winchester, contributing authors were David J. Bentrem, MD, FACS,(Northwestern University); Nora M. Hansen, MD, FACS, (Northwestern University); Kevin P. Bethke, MD, FACS,(Northwestern University); Alfred W. Rademaker, PhD, (Northwestern University); Clifford Y. Ko, MD, FACS, (University of California at Los Angeles and VA Greater Los Angeles Healthcare System); David P. Winchester, MD, FACS, (North Shore University Health System).

The National Cancer Data Base--a joint program supported by the American College of Surgeons Commission on Cancer and the American Cancer Society--is recognized as the largest clinical registry in the world. It is a nationwide oncology outcomes database for more than 1,460 Commission on Cancer accredited cancer programs in the United States and Puerto Rico, and captures approximately 70 percent of all new invasive cancers diagnosed annually.

The study was supported by the American College of Surgeons Clinical Scholars in Residence program and the Department of Surgery, Feinberg School of Medicine, Northwestern University.

Citation: Karl Y. Bilimoria, David J. Bentrem, Nora M. Hansen, Kevin P. Bethke, Alfred W. Rademaker, Clifford Y. Ko, David P. Winchester, and David J. Winchester. Comparison of Sentinel Lymph Node Biopsy Alone and Completion Axillary Lymph Node Dissection for Node-Positive Breast Cancer. JCO Apr 13 2009: doi:10.1200/JCO.2008.19.5750.

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The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.

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