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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.

Abstract

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.

References
1.
Giuliano  AE, Hunt  KK, Ballman  KV,  et al.  Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.  JAMA. 2011;305(6):569-575. doi:10.1001/jama.2011.90PubMedGoogle ScholarCrossref
2.
Galimberti  V, Cole  BF, Zurrida  S,  et al; International Breast Cancer Study Group Trial 23-01 investigators.  Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial.  Lancet Oncol. 2013;14(4):297-305. doi:10.1016/S1470-2045(13)70035-4PubMedGoogle ScholarCrossref
3.
Donker  M, van Tienhoven  G, Straver  ME,  et al.  Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial.  Lancet Oncol. 2014;15(12):1303-1310. doi:10.1016/S1470-2045(14)70460-7PubMedGoogle ScholarCrossref
4.
Moran  MS, Schnitt  SJ, Giuliano  AE,  et al; Society of Surgical Oncology; American Society for Radiation Oncology.  Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer.  J Clin Oncol. 2014;32(14):1507-1515. doi:10.1200/JCO.2013.53.3935PubMedGoogle ScholarCrossref
5.
Morrow  M, Abrahamse  P, Hofer  TP,  et al.  Trends in reoperation after initial lumpectomy for breast cancer: addressing overtreatment in surgical management.  JAMA Oncol. 2017;3(10):1352-1357. doi:10.1001/jamaoncol.2017.0774PubMedGoogle ScholarCrossref
6.
Farrow  DC, Hunt  WC, Samet  JM.  Geographic variation in the treatment of localized breast cancer.  N Engl J Med. 1992;326(17):1097-1101. doi:10.1056/NEJM199204233261701PubMedGoogle ScholarCrossref
7.
Gilligan  MA, Kneusel  RT, Hoffmann  RG, Greer  AL, Nattinger  AB.  Persistent differences in sociodemographic determinants of breast conserving treatment despite overall increased adoption.  Med Care. 2002;40(3):181-189. doi:10.1097/00005650-200203000-00002PubMedGoogle ScholarCrossref
8.
Morrow  M, White  J, Moughan  J,  et al.  Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma.  J Clin Oncol. 2001;19(8):2254-2262. doi:10.1200/JCO.2001.19.8.2254PubMedGoogle ScholarCrossref
9.
Rockwood  TH, Sangster  RL, Dillman  DA.  The effect of response categories on survey questionnaires: context and mode effects.  Sociol Methods Res. 1997;26:118-140. doi:10.1177/0049124197026001004Google ScholarCrossref
10.
Azu  M, Abrahamse  P, Katz  SJ, Jagsi  R, Morrow  M.  What is an adequate margin for breast-conserving surgery? surgeon attitudes and correlates.  Ann Surg Oncol. 2010;17(2):558-563. doi:10.1245/s10434-009-0765-1PubMedGoogle ScholarCrossref
11.
Samejima  F.  Estimation of Latent Ability Using a Response Pattern of Graded Scores: Psychometric Monograph 17. Richmond, VA: Psychometric Society; 1969.
12.
Morrow  M, Van Zee  KJ, Patil  S,  et al.  Axillary dissection and nodal irradiation can be avoided for most node-positive z0011-eligible breast cancers: a prospective validation study of 793 patients.  Ann Surg. 2017;266(3):457-462. doi:10.1097/SLA.0000000000002354PubMedGoogle ScholarCrossref
13.
Amin  MB, Edge  SB, Greene  FL,  et al, eds.  American Joint Committee on Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017. doi:10.1007/978-3-319-40618-3
14.
National Institutes of Health Consensus Development Panel.  Consensus statement: treatment of early-stage breast cancer.  J Natl Cancer Inst Monogr. 1992;(11):1-5.PubMedGoogle Scholar
15.
Albornoz  CR, Matros  E, Lee  CN,  et al.  Bilateral mastectomy versus breast-conserving surgery for early-stage breast cancer: the role of breast reconstruction.  Plast Reconstr Surg. 2015;135(6):1518-1526. doi:10.1097/PRS.0000000000001276PubMedGoogle ScholarCrossref
16.
Goyal  A, Dodwell  D.  POSNOC: a randomised trial looking at axillary treatment in women with one or two sentinel nodes with macrometastases.  Clin Oncol (R Coll Radiol). 2015;27(12):692-695. doi:10.1016/j.clon.2015.07.005PubMedGoogle ScholarCrossref
17.
Güth  U, Myrick  ME, Viehl  CT, Schmid  SM, Obermann  EC, Weber  WP.  The post ACOSOG Z0011 era: does our new understanding of breast cancer really change clinical practice?  Eur J Surg Oncol. 2012;38(8):645-650. doi:10.1016/j.ejso.2012.04.018PubMedGoogle ScholarCrossref
18.
Giuliano  AE, Ballman  KV, McCall  L,  et al.  Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) randomized clinical trial.  JAMA. 2017;318(10):918-926. doi:10.1001/jama.2017.11470PubMedGoogle ScholarCrossref
19.
Lucci  A, McCall  LM, Beitsch  PD,  et al; American College of Surgeons Oncology Group.  Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011.  J Clin Oncol. 2007;25(24):3657-3663. doi:10.1200/JCO.2006.07.4062PubMedGoogle ScholarCrossref
20.
Mansel  RE, Fallowfield  L, Kissin  M,  et al.  Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial.  J Natl Cancer Inst. 2006;98(9):599-609. doi:10.1093/jnci/djj158PubMedGoogle ScholarCrossref
21.
Fleissig  A, Fallowfield  LJ, Langridge  CI,  et al.  Post-operative arm morbidity and quality of life: results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer.  Breast Cancer Res Treat. 2006;95(3):279-293. doi:10.1007/s10549-005-9025-7PubMedGoogle ScholarCrossref
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