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Surgeon Attitudes Toward the Omission of Axillary Dissection in Early Breast Cancer

Educational Objective
To learn whether surgeons have accepted omission of axillary dissection in patients with sentinel node–positive disease who are undergoing breast-conserving surgery and be aware of surgeon characteristics associated with omission of axillary dissection.
1 Credit CME
Key Points

Question  Have surgeons accepted sentinel node biopsy alone for axillary management in patients undergoing breast-conserving surgery?

Findings  In this survey of 376 surgeons, 49% would definitely or probably recommend axillary dissection for 1 sentinel node macrometastasis and 63% would definitely or probably recommend axillary dissection for 2 sentinel node macrometastases. In multivariable analysis, a lower propensity for axillary dissection was significantly associated with treatment of more breast cancer cases, acceptance of a lumpectomy margin of no ink on tumor, multidisciplinary tumor board participation, and Los Angeles Surveillance, Epidemiology, and End Results site.

Meaning  The potential for overtreatment identified in this study indicates the need for education targeted toward lower-volume breast surgeons.


Importance  The American College of Surgeons Oncology Group (ACOSOG) Z0011 study demonstrated the safety of sentinel node biopsy alone in clinically node-negative women with metastases in 1 or 2 sentinel nodes treated with breast conservation. Little is known about surgeon perspectives regarding when axillary lymph node dissection (ALND) can be omitted.

Objectives  To determine surgeon acceptance of ACOSOG Z0011 findings, identify characteristics associated with acceptance of ACOSOG Z0011 results, and examine the association between acceptance of the Society of Surgical Oncology and American Society for Radiation Oncology negative margin of no ink on tumor and surgeon preference for ALND.

Design, Setting, and Participants  A survey was sent to 488 surgeons treating a population-based sample of women with early-stage breast cancer (N = 5080). The study was conducted from July 1, 2013, to August 31, 2015.

Main Outcomes and Measures  Surgeons were categorized as having low, intermediate, or high propensity for ALND according to the outer quartiles of ALND scale distribution. A multivariable linear regression model was used to confirm independent associations.

Results  Of the 488 surgeons invited to participate, 376 (77.0%) responded and 359 provided complete information regarding propensity for ALND derived from 5 clinical scenarios. Mean surgeon age was 53.7 (range, 31-80) years; 277 (73.7%) were male; 142 (37.8%) treated 20 or fewer breast cancers annually and 108 (28.7%) treated more than 50. One hundred seventy-five (49.0%) recommended ALND for 1 macrometastasis. Of low-propensity surgeons who recommended ALND, only 1 (1.1%) approved ALND for any nodal metastases compared with 69 (38.6%) and 85 (95.5%) of selective and high-propensity surgeons (P < .001), respectively. In multivariable analysis, lower ALND propensity was significantly associated with higher breast cancer volume (21-50: −0.19; 95% CI, −0.39 to 0.02; >51: −0.48; 95% CI, −0.71 to −0.24; P < .001), recommendation of a minimal margin width (1-5 mm: −0.10; 95% CI, −0.43 to 0.22; no ink on tumor: −0.53; 95% CI, −0.82 to −0.24; P < .001), participation in a multidisciplinary tumor board (1%-9%: −0.25; 95% CI, −0.55 to 0.05; >9%: −0.37; 95% CI, −0.63 to −0.11; P = .02), and Los Angeles Surveillance, Epidemiology, and End Results site (−0.18; 95% CI, −0.35 to −0.01; P = .04).

Conclusions and Relevance  This study shows substantial variation in surgeon acceptance of more limited surgery for breast cancer, which is associated with higher breast cancer volume and multidisciplinary interactions, suggesting the potential for overtreatment of many patients and the need for education targeting lower-volume breast surgeons.

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Article Information

Corresponding Author: Monica Morrow, MD, Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY 10065 (morrowm@mskcc.org).

Accepted for Publication: April 4, 2018.

Published Online: July 12, 2018. doi:10.1001/jamaoncol.2018.1908

Author Contributions: Dr Morrow had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Morrow, Jagsi, Katz.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Morrow, McLeod, Katz.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: McLeod.

Obtained funding: Morrow, Jagsi, Katz.

Administrative, technical, or material support: Morrow.

Conflict of Interest Disclosures: No conflicts were reported.

Funding/Support: This work was funded by grant P01 CA163233 to the University of Michigan from the National Cancer Institute.

Role of the Funder/Sponsor: The funding agency had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This study was presented in part at the 2017 American Society of Clinical Oncology Annual Meeting; June 5, 2017; Chicago, Illinois.

Disclaimer: Dr Morrow is Associate Editor for Reviews and CME of JAMA Oncology, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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