A Population-Based Study of the Effects of a Regional Guideline for Completion Axillary Lymph Node Dissection on Axillary Surgery in Patients with Breast Cancer

• Published in: Annals of surgical oncology 2016-10, Vol.23 (10), p.3354-3364
• Main Authors: Tsao, Miriam W., Cornacchi, Sylvie D., Hodgson, Nicole, Simunovic, Marko, Thabane, Lehana, Cheng, Ji, O’Brien, Mary Ann, Strang, Barbara, Mukherjee, Som D., Lovrics, Peter J.
• Format: Article
• Language: English
• Subjects: Age Factors; Aged; Area Under Curve; Axilla; Breast Neoplasms - pathology; Breast Neoplasms - surgery; Breast Oncology; Female; Humans; Interrupted Time Series Analysis; Lymph Node Excision - utilization; Lymph Nodes - pathology; Lymph Nodes - surgery; Lymphatic Metastasis; Medicine; Medicine & Public Health; Middle Aged; Neoplasm Staging; Oncology; Practice Guidelines as Topic; ROC Curve; Sentinel Lymph Node Biopsy - utilization; Surgery; Surgical Oncology; Tumor Burden
• ISSN: 1068-9265; 1534-4681
• DOI: 10.1245/s10434-016-5310-4

Introduction Evidence from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial suggests completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy (+SLNB) does not improve outcomes in select patients, leading to practice variation. A multidisciplinary group of surgeons, oncologists, and pathologists developed a regional guideline for cALND which was disseminated in August 2012. We assessed the impact of Z0011 and the regional guideline on cALND rates. Methods Consecutive invasive breast cancer cases undergoing SLNB were reviewed at 12 hospitals. Patient, tumor, and process measures were collected for three time periods: TP1, before publication of Z0011 (May 2009–August 2010); TP2, after publication of Z0011 (March 2011–June 2012); and TP3, after guideline dissemination (January 2013–April 2014). Cases were categorized by whether they met the guideline criteria for cALND (i.e. ≤50 years, mastectomy, T3 tumor, three or more positive sentinel lymph nodes [SLNs]) or not (e.g. age > 50 years, breast-conserving surgery, T1/T2 tumor, and one to two positive SLNs). Results The SLNB rate increased from 56 % ( n   =  620), to 70 % ( n   =  774), to 78 % ( n   =  844) in TP1, TP2, and TP3, respectively. Among cases not recommended for cALND using the guideline criteria, cALND rates decreased significantly over time (TP1, 71 %; TP2, 43 %; TP3, 17 %) [ p