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


Key Points

  • Lower propensity for ALND was associated with higher surgical volume.
  • Lower propensity was also associated with preferred minimal surgical margin and greater participation in multidisciplinary tumor boards.

In a study reported in JAMA Oncology, Morrow and colleagues found that surgeon acceptance of more limited surgery in early breast cancer was more likely among high-volume surgeons and those preferring a surgical margin of “no ink on tumor.”

As noted by the authors, the American College of Surgeons Oncology Group Z0011 study showed the safety of sentinel node biopsy alone in clinically node-negative women with metastases in 1 or 2 sentinel nodes who received breast-conserving surgery. The current study was aimed at determining surgeon acceptance of such findings, supporting less use of axillary lymph node dissection (ALND).

The study involved a survey of 488 surgeons treating a population-based sample of women with early-stage breast cancer (n = 5,080).  Of these, 376 (77%) responded and 359 provided complete information regarding propensity for ALND derived from 5 clinical scenarios. The mean age of the surgeons was 53.7 years (range = 31–80 years); 277 (74%) were male;142 (38%) treated ≤ 20 breast cancers annually; and 108 (29%) treated > 50. Surgeons were categorized as having a low (n = 88), selective (n = 176), or high (n = 88) propensity for ALND on the basis of lowest and highest quartiles of the ALND scale distribution derived from the survey.

ALND Propensity

Overall, 175 surgeons (49.0%) recommended ALND for 1 macrometastasis. Of low-propensity surgeons who recommended ALND, 1 (1.1%) approved ALND for any nodal metastases vs 69 (38.6%) and 85 (95.5%) of selective and high-propensity surgeons (P < .001).

On multivariate analysis, lower ALND propensity (higher negative value propensity coefficient) was significantly associated with higher surgeon breast cancer volume (coefficient = −0.19, 95% confidence interval [CI] =  −0.39 to 0.02, for 21–50 cases per year and −0.48, 95% CI = −0.71 to −0.24, for > 51 cases per year vs ≤ 20 cases per year; P < .001). A lower ALND propensity was also significantly associated with the recommendation of a minimal margin width (−0.10, 95% CI = −0.43 to 0.22 for 1–5 mm, and  −0.53, 95% CI = −0.82 to −0.24, for no ink on tumor vs > 5 mm; P < .001) and percentage of cases with participation in a multidisciplinary tumor board (−0.25, 95% CI = −0.55 to 0.05, for 1% to 9% and  −0.37, 95% CI = −0.63 to −0.11, for > 9%; P = .02).

The investigators concluded, “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.”

The study was funded by a grant from the National Cancer Institute. Monica Morrow, MD, of the Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, is the corresponding author for the JAMA Oncology article.

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®.