Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP
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ORIGINAL ARTICLE – BREAST ONCOLOGY
Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP Database: Are We Following National Guidelines? Bryan J. Pyfer, MD, MBA1, Michael Jonczyk, MD2, Jolie Jean, BS3, Roger A. Graham, MD2, Lilian Chen, MD2, and Abhishek Chatterjee, MD, MBA2 1
Duke University Medical Center, Durham, NC; 2Tufts Medical Center, Boston, MA; 3Tufts University Medical School, Boston, MA
ABSTRACT Background. For patients with ductal carcinoma in situ (DCIS), multiple national cancer organizations recommend that sentinel lymph node biopsy (SLNB) be offered when treated with mastectomy, but not when treated with breastconserving surgery (BCS). This study analyzes national surgical trends of SLNB and axillary lymph node dissection (ALND) in DCIS patients undergoing breast surgery with the aim to quantify deviations from national guidelines. Methods. A retrospective cohort analysis of the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2017 identified patients with DCIS. Patients were categorized by their primary method of breast surgery, i.e. mastectomy or BCS, then further categorized by their axillary lymph node (ALN) management, i.e. no intervention, SLNB, or ALND. Data analysis was conducted via linear regression and a non-parametric Mann–Kendall test to assess a temporal trend and Sen’s slope. Results. Overall, 43,448 patients with DCIS met the inclusion criteria: 20,504 underwent mastectomy and 22,944 underwent BCS. Analysis of DCIS patients from
This manuscript represents original research that was presented as an invited podium presentation at the 2019 Society of Surgical Oncology Annual Cancer Symposium. Ó Society of Surgical Oncology 2020 First Received: 5 April 2019 B. J. Pyfer, MD, MBA e-mail: [email protected]
2005 to 2017 revealed that ALND decreased and SLNB increased in every subgroup, regardless of surgical treatment modality. Evaluation in the mastectomy group increased overall: mastectomy alone increased from 57.1 to 65.8% (p \ 0.01) and mastectomy with immediate reconstruction increased from 58.5 to 72.1% (p \ 0.01). Increases also occurred in the total BCS population: partial mastectomy increased from 14.0 to 21.1% and oncoplastic surgery increased from 10.5 to 23.0% (both p \ 0.01). Conclusions. Despite national guideline recommendations for the management of ALN surgery in DCIS patients, approximately 20–30% of cases continue to not follow these guidelines. This warrants further education for surgeons and patients.
The axillary lymph node (ALN) basin serves as the first site of spread for many breast cancers. As such, surgical evaluation of nodes guided by ALN mapping has been a crucial component of breast cancer treatment since the early 1990s.1 ALN evaluation at the time of breast surgery has proven to decrease the rates of cancer metastasis and improve short- and long-term mortality;2,3 however, recent trends in lymph node management have favored
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