Hospital and Surgeon Factors Associated With Axillary Lymph Node Evaluation in DCIS
In a study reported in JAMA Oncology, Coromilas et al found that axillary lymph node evaluation is frequently performed in women with ductal carcinoma in situ (DCIS), and a number of hospital or surgeon characteristics are associated with likelihood of evaluation. As noted by the authors, benefit of axillary evaluation in this setting has not been demonstrated.
Study Details
The study involved cross-sectional analysis of medical records in the Perspective database for women with DCIS who underwent breast-conserving surgery or mastectomy from January 2006 to December 2012. A total of 35,591 women aged 18 to 90 years were included in the analysis.
Frequency of Axillary Evaluation
Overall, 9,011 women (25.3%) underwent mastectomy and 26,580 (74.7%) underwent breast-conserving surgery. Axillary evaluation was performed in 63.0% of those undergoing mastectomy and 17.7% of those undergoing breast-conserving surgery.
Among women undergoing mastectomy, the frequency of axillary evaluation increased from 56.6% in 2006 to 67.4% in 2012, with frequency of sentinel lymph node biopsy increasing from 36.5% to 56.7% and frequency of axillary lymph node dissection decreasing from 20.0% to 10.7%. Among women undergoing breast-conserving surgery, the frequency of axillary evaluation was 18.5% in 2006 and 16.2% in 2012, with the frequency of axillary lymph node dissection decreasing from 1.2% to 0.3%.
Hospital/Surgeon Factors
In multivariate analysis, factors associated with likelihood of axillary evaluation in patients undergoing mastectomy included treatment at a nonteaching hospital (risk ratio [RR] = 1.17, 95% confidence interval [CI] = 1.05–1.30), hospital in an urban location (RR = 1.15, 95% CI = 1.03–1.29), and hospital in the west vs northeast region of the United States (RR = 0.89, 95% CI = 0.81–0.99).
Factors associated with likelihood of axillary evaluation among women undergoing breast-conserving surgery included treatment at a nonteaching hospital (RR = 1.17, 95% CI = 1.03–1.33) and surgeon volume (RR = 0.87, 95% CI = 0.70–0.94, for mid [>1–2.67 procedures/year] vs low volume [1 procedure/year]; RR = 0.54, 95% CI = 0.44–0.65, for high [> 2.67 per year] vs low volume).
The investigators concluded: “Despite guidelines recommending against axillary lymph node evaluation in women with DCIS undergoing [breast-conserving surgery] and uncertainty regarding its use with mastectomy, [sentinel lymph node biopsy] or [axillary lymph node dissection] is performed frequently. Given the additional morbidity and cost of these procedures, alternative surgical approaches or prospective evaluation of the clinical benefit of axillary evaluation in women with DCIS is needed.”
Dawn L. Hershman, MD, MS, of Columbia University Medical Center, is the corresponding author for the JAMA Oncology article.
The study was supported by a grant from the Breast Cancer Research Foundation. The authors reported no conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
