Axillary lymph node dissection for breast cancer: a decision analysis of T1 lesions

Early self-reported impairments in arm functioning of primary breast cancer patients predict late side effects of axillary lymph node dissection: results from a population-based cohort study

OBJECTIVES

Improvements in the life expectancy of women with breast cancer raise important questions how to improve quality of life (QoL) for women sustaining complications and side effects of cancer treatment. The presented study examined the prevalence of arm morbidity in a cohort of primary breast cancer patients over time as a result of the extent of axillary lymph node dissection. Of particular interest is the question of using a recognized QoL assessment instrument at defined assessment points as an endpoint criteria of oncological treatment.

METHODS

A prospective, population-based, longitudinal cohort study of patients with primary breast cancer was performed (n = 389). QoL data (EORTC QLQ C30 + BR23) and clinical data were assessed at designated time points. Primary endpoint of this analysis was patient reported arm morbidity assessed with the three-idem scale in the BR 23 (swelling, moving, pain).

RESULTS

20% of the patients evidenced considerable impairments in arm functioning. Arm morbidity was significantly related to the number of lymph nodes dissected (P < 0.002 entire cohort, P < 0.001 lymph node negatives) and was independent of age, stage of the disease, kind of breast surgery and radiation treatment. Early impairments in arm functioning (below 50 score values) assessed within 6 months after axillary surgery was a good predictor for late arm morbidity at 12 months RR 11.5 (CI 95% 4.7-28.4), 24 months RR 6.0 (CI95% 2.8-13.3) and 36 months RR 3.8 (CI 95% 1.8-7.9).

CONCLUSIONS

Arm morbidity after axillary surgery is a severe and chronic condition affecting many breast cancer patients. The recognized QoL assessment instrument depict patients with severe impairments in arm functioning after axillary lymph node dissection and predict late arm morbidity. To increase patients' quality of life it thus may serve as a valid assessment tool for screening, allowing early referral for treatment and monitoring.

Uncertainty and the value of diagnostic information, with application to axillary lymph node dissection in breast cancer

In clinical decision making, it is common to ask whether, and how much, a diagnostic procedure is contributing to subsequent treatment decisions. Statistically, quantification of the value of the information provided by a diagnostic procedure can be carried out using decision trees with multiple decision points, representing both the diagnostic test and the subsequent treatments that may depend on the test's results. This article investigates probabilistic sensitivity analysis approaches for exploring and communicating parameter uncertainty in such decision trees. Complexities arise because uncertainty about a model's inputs determines uncertainty about optimal decisions at all decision nodes of a tree. We present the expected utility solution strategy for multistage decision problems in the presence of uncertainty on input parameters, propose a set of graphical displays and summarization tools for probabilistic sensitivity analysis in multistage decision trees, and provide an application to axillary lymph node dissection in breast cancer.

Outcomes and quality of life following breast cancer treatment in older women: when, why, how much, and what do women want?

BACKGROUND

There are few comprehensive reviews of breast cancer outcomes in older women. We synthesize data to describe key findings and gaps in knowledge about the outcomes of breast cancer in this population.

METHODS

We reviewed research published between 1995 and June 2003 on breast cancer quality of life and outcomes among women aged 65 and older treated for breast cancer. Outcomes included communication, satisfaction, and multiple quality of life domains.

RESULTS

Few randomized trials or cohort studies that measured quality of life after treatment focused exclusively on older women. Studies from older women generally noted that, with the exception of axillary dissection, type of surgical treatment generally had no effect on long-term outcomes. In contrast, the processes of care, such as choosing therapy, good patient-physician communication, receiving treatment concordant with preferences about body image, and low perceptions of bias, were associated with better quality of life and satisfaction.

CONCLUSIONS

With the exception of axillary dissection, the processes of care, and not the therapy itself, seem to be the most important determinants of long-term quality of life in older women.

Small invasive breast carcinomas in Taiwanese women

BACKGROUND

Female Taiwanese breast cancer patients are younger than their Western counterparts. This study examined the predictors of axillary lymph node metastases in Taiwanese women with T1 breast cancer.

METHODS

Data from 394 Taiwanese women with T1 invasive breast carcinoma were retrospectively reviewed.

RESULTS

The data contained 6 T1a, 51 T1b, and 337 T1c breast tumors. The patients' ages ranged from 23 to 82 years (mean +/- SD, 48.2 +/- 11.4 years; median, 46.4 years). Axillary nodal metastases were present in 38.3% of the patients (16.7% in T1a, 35.3% in T1b, and 39.2% in T1c tumors). The patients with nodal metastases had significantly greater body weights and S-phase fractions than those without nodal metastases. Univariate analysis revealed that unfavorable pathology, lymphovascular invasion, S-phase fraction >7%, and nondiploid DNA ploidy were significantly associated with lymph node metastases. Lymphovascular invasion was the only significant variable as the independent predictor in the multiple logistic regression analysis. In the Cox proportional hazards regression analysis, axillary nodal status and lymphovascular invasion were significantly associated with survival.

CONCLUSIONS

Taiwanese women with small breast cancer displayed a relatively higher incidence of axillary lymph node metastases than Western women. Axillary lymph node dissection or sentinel lymph node biopsy should be conducted on Taiwanese patients with small invasive breast carcinomas, particularly when risk factors exist.

Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care

PURPOSE

There are few data on sequelae of breast cancer treatments in older women. We evaluated posttreatment quality of life and satisfaction in a national population.

PATIENTS AND METHODS

Telephone surveys were conducted with a random cross-sectional sample of 1,812 Medicare beneficiaries 67 years of age and older who were 3, 4, and 5 years posttreatment for stage I and II breast cancer. Regression models were used to estimate the adjusted risk of decrements in physical and mental health functioning by treatment. In a subset of women (n = 732), additional data were used to examine arm problems, impact of cancer, and satisfaction, controlling for baseline health, perceptions of ageism and racism, demographic and clinical factors, region, and surgery year.

RESULTS

Use of axillary dissection was the only surgical treatment that affected outcomes, increasing the risk of arm problems four-fold (95% confidence interval, 1.56 to 10.51), controlling for other factors. Having arm problems, in turn, exerted a consistently negative independent effect on all outcomes (P </=.001). Processes of care were also associated with quality of life and satisfaction. For example, women who perceived high levels of ageism or felt that they had no choice of treatment reported significantly more bodily pain, lower mental health scores, and less general satisfaction. These same factors, as well as high perceived racism, were significantly associated with diminished satisfaction with the medical care system.

CONCLUSION

With the exception of axillary dissection, the processes of care, and not the therapy itself, are the most important determinants of long-term quality of life in older women.

Survival of lymph node-negative breast cancer patients in relation to number of lymph nodes examined

OBJECTIVE

To assess the relationship between number of lymph nodes examined and survival of patients diagnosed with node-negative localized breast cancer using a large sample of patients from population-based cancer registries in the United States.

SUMMARY BACKGROUND DATA

Conflicting results have been reported from studies on the relationship between number of lymph nodes examined and survival of patients diagnosed with node-negative localized breast cancer.

METHODS

The study included 69,543 patients diagnosed in 1988-97 with localized invasive node-negative breast cancer reported to nine population-based registries in the U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program of population-based cancer registries. Hazard ratios for groups defined by number of nodes examined were analyzed in Cox proportional hazards regression models that included age, tumor size and grade, race/ethnicity, and other variables.

RESULTS

A significantly higher risk of death from breast cancer was found among patients with 0, 1 to 3, or 4 to 10 nodes examined than with 20-plus nodes examined, even among patients with tumors 2 cm or smaller.

CONCLUSIONS

Future studies of survival of node-negative patients, by number of nodes examined, should include information on comorbidity and treatment.

Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma

BACKGROUND

There are few data on the long-term sequelae of axillary dissection among older breast carcinoma patients. We describe the impact of axillary dissection in a cohort of older women.

METHODS

A longitudinal cohort of 571 patients with Stage 1 and 2 breast carcinoma, 67 years and older, diagnosed between 1995 and 1997 from 29 hospitals in five regions, and followed for 2 years. Data were collected from patients and medical charts. The primary outcome was posttreatment quality of life. Generalized estimation equation longitudinal modeling was used to evaluate the outcome, controlling for baseline function, comorbidity, age, clinical status, and other factors.

RESULTS

Sixty percent of women reported arm problems at some time in the 2 years after surgery. The cumulative risk of having arm problems 2 years posttreatment was three times higher (95% confidence interval 1.94-4.67) for women who underwent axillary surgery compared with women without axillary surgery, controlling for covariates. The effects of having axillary dissection and arthritis were multiplicative 2 years postsurgery. Arm problems were, in turn, the primary determinate of lower physical and mental functioning (P = 0.0001 and 0.04, respectively), controlling for other factors. Undergoing axillary dissection did not lessen fears about recurrence.

CONCLUSIONS

Arm problems after axillary dissection have a consistent negative impact on quality of life, suggesting that the risks may outweigh the potential benefits in this population.

Optimal use of sentinel lymph node biopsy versus axillary lymph node dissection in patients with breast carcinoma: a decision analysis

BACKGROUND

There are no data available from randomized controlled trials that compare the efficacy of sentinel lymph node (SLN) biopsy with Level I/II axillary lymph node dissection (ALND) in patients with breast carcinoma. We performed a formal decision analysis to determine whether SLN biopsy is appropriate, compared with ALND, for patients with T1, T2, and T3 tumors and to quantify the relative value of these two procedures in the management of patients with breast carcinoma.

METHODS

All clinically relevant outcomes were modeled for both SLN biopsy and ALND. The probabilities of complications and outcomes were derived using data from the University of Louisville Breast Cancer Sentinel Lymph Node Study and from extensive review of previous studies. Utilities were assigned by the authors, incorporating values from the literature whenever possible.

RESULTS

The expected utility of SLN biopsy was higher than the expected utility for ALND for T1 and T2 tumors that were 4.0 cm or smaller. There was no clear preference for either procedure with tumors that were larger than 4.0 cm. The T1 and T2 results were robust to sensitivity analysis.

CONCLUSIONS

The results of this decision analysis suggest that SLN biopsy is preferred over ALND for patients with breast tumors that are 4.0 cm or smaller. Patients should be aware of the potential for false-negative results in SLN biopsy, but this risk is outweighed by the decreased morbidity associated with the procedure itself.

Observation of the breast cancer patient with a tumor-positive sentinel node: implications of the ACOSOG Z0011 trial

Axillary lymph node status has been the most important prognostic factor for breast cancer throughout the past century. During the past decade, intraoperative lymphatic mapping with sentinel lymph node dissection (SLND) has been investigated as an alternative staging modality. This technique may be as accurate as ALND, and certainly is less invasive. Adjuvant treatment recommendations, which historically were made on the basis of lymph node status alone, now take into account primary tumor features, molecular markers, and patient characteristics. This evolution of current treatment patterns is driven in part by the diminishing size of tumors, the simultaneous decrease in the presence of axillary metastases, and a better understanding of tumor-specific risk factors. How do these trends affect the interpretation of a tumor-positive sentinel node (SN)? Can an axilla with a positive SN be observed? Should it be observed? This review examines the implications of a positive SN in the context of smaller tumor size, decreased nodal disease, and increased reliance on alternative prognostic factors for treatment decisions. The historical data comparing ALND to no ALND in clinically node-negative patients is reviewed and discussed in the context of observation for a positive SN. These are the issues underlying the ACOSOG Z0010 and Z0011 trials.

Axillary lymph node dissection in breast cancer--current status and controversies, alternative strategies and future perspectives

Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure in the surgical management of patients with breast cancer. The goals of ALND in breast cancer surgery are: (a) to provide accurate prognostic information, (b) to maintain local control of the disease in the axilla and (c) to provide a rational basis for decisions about adjuvant therapy. Although controversial, ALND may also be associated with a small therapeutic benefit. Recently, the question of whether ALND is needed for every patient with invasive breast cancer has been the subject of ongoing debate in the literature. This is mainly due to the widespread use of adjuvant systemic therapy for patients with node-negative breast cancer and to the increasingly frequent detection of small invasive cancers by mammographic screening; the majority of these patients have negative axillae. Sentinel lymph node (SLN) biopsy is a new, promising, minimally invasive procedure, which accurately predicts nodal status with minimal morbidity, and reserves ALND for patients with positive SLN biopsies. However, this method is still investigational. Partial (levels I and II) ALND remains the gold standard in the surgical management of patients with breast cancer.

Six-year follow-up of patients with microinvasive, T1a, and T1b breast carcinoma

BACKGROUND

Management of patients with breast cancers < or = 1 cm remains controversial. Reports of infrequent nodal metastases in tumors < or = 5 mm has led to suggestions that axillary dissection should be selective, and that tumor characteristics should guide adjuvant therapy.

METHODS

A retrospective review of 290 patients with breast cancer 1 cm in size or smaller from 1989 to 1991 was done. Distant disease-free survival (DDFS) was the primary outcome measure.

RESULTS

There were 95 T1a (< or = 5 mm) and 196 T1b (6-10 mm) cancers. Nodal metastases were found in 8 T1a and 26 T1b tumors. Larger size, poorer differentiation, and lymphovascular invasion (LVI) were associated with more nodal metastases, but none of these trends reached statistical significance. The 6-year DDFS was 93% for node-negative and 87% for node-positive patients (P = .02). Overall, breast cancers with poorer differentiation and LVI trended toward a poorer outcome. For patients with node-negative tumors, LVI was associated with a poorer outcome (P = .03). The size of the primary tumor was not predictive of outcome. There were no nodal metastases or recurrences in the 18 patients with microinvasive breast cancer.

CONCLUSIONS

Lymph node status is the major determinant of outcome in breast cancers 1 cm in size or smaller. Accurate axillary assessment remains crucial in management of small breast cancer.

Is axillary lymph node dissection indicated for early-stage breast cancer? A decision analysis

PURPOSE

Axillary lymph node dissection (ALND) has been a standard procedure in the management of breast cancer. In a patient with a clinically negative axilla, ALND is performed primarily for staging purposes, to guide adjuvant treatment. Recently, the routine use of ALND has been questioned because the results of the procedure may not change the choice of adjuvant systemic therapy and/or the survival benefit of a change in adjuvant therapy would be small. We constructed a decision model to quantify the benefits of ALND for patients eligible for breast-conserving therapy.

METHODS

Patients were grouped by age, tumor size, and estrogen receptor (ER) status. The model uses the Oxford overviews and three combined Cancer and Leukemia Group B studies. We assumed that patients who did not undergo ALND received axillary radiation therapy and that the two procedures are equally effective. All chemotherapy combinations were assumed to be equally efficacious.

RESULTS

The largest benefits from ALND are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-negative women, almost all of whom would receive adjuvant chemotherapy. When adjusted for quality of life (QOL), ALND may have an overall negative impact. In general, the benefits of ALND increase with the expected severity of adjuvant therapy on QOL CONCLUSION: Our model quantifies the benefits of ALND and assists decision making by patients and physicians. The results suggest that the routine use of ALND in breast cancer patients should be reassessed and may not be necessary in many patients.

Quality of life of breast cancer patients with lymphedema

BACKGROUND

Quality of life has increasingly become an important issue in breast cancer treatment. One of the impetuses for sentinel lymph node biopsy or selective axillary lymph node dissection (ALND) is the assumed decreased incidence of lymphedema compared with standard ALND. This is based on the assumption that ALND is associated with a clinically significant incidence of lymphedema and that this lymphedema decreases the quality of life of these patients. However, few data exist on this issue. This study attempts to define the incidence and effect on quality of life of postoperative lymphedema in breast cancer patients.

METHODS

To determine the incidence of postoperative lymphedema, the Breast Cancer Registry at Henry Ford Hospital was accessed to obtain information on all patients who underwent ALND in the management of breast cancer over a 7-year period. The registry is a prospectively gathered data base to include the development of various complications, such as lymphedema. To determine the effects of lymphedema on quality of life, 101 consecutive, unselected patients who underwent breast surgery were asked to complete the SF-36, a generic quality of life instrument. The SF-36 measures eight domains of quality of life. Patients were then divided into three groups: (1) breast surgery without ALND (-ALND), (2) breast surgery with ALND but no lymphedema (-LE), and (3) breast surgery with ALND and lymphedema (+LE).

RESULTS

In all, 827 patients with ALND were identified in the registry. Of these, 8.3% developed clinically apparent lymphedema. Patients in -ALND and -LE groups had similar scores in all domains of the SF-36. However, patients in the +LE group had significantly lower scores in the domains of role-emotional and bodily pain. A significantly higher percentage of patients in the +LE group had scores below one standard deviation compared with national norms in the domains of bodily pain (P = 0.005), mental health (P = 0.01), and general health (P = 0.04).

CONCLUSIONS

Although postoperative lymphedema occurs in a minority of patients, when it does occur it can produce demonstrable diminutions in quality of life. Therefore, efforts to reduce the incidence of lymphedema, such as sentinel lymph node biopsy or selective ALND, would benefit breast cancer patients.

Lymph node metastasis in breast cancer: common prognostic markers lack predictive value

BACKGROUND

The purpose of this study was to determine whether routine biologic tumor markers can predict lymph node status. The authors attempted to discover whether predictors of axillary lymph node metastasis based on biologic characteristic of primary breast cancers exist.

METHODS

Eight hundred and fifty-one patients with invasive breast cancer who underwent surgical treatment, including axillary lymph node dissection, at a tertiary referral center were studied. Univariate and multivariate analysis were performed on prospectively gathered data from a breast cancer registry, including pathology, site of primary lesion in the breast, estrogen and progesterone receptor status, DNA index, S-phase fraction, nuclear grade, and extensive intraductal component. Outcome was determined by (1) the presence of any lymph node metastasis and (2) the presence of 10 or more lymph node metastases.

RESULTS

The only independent predictors of lymph node metastasis were primary tumor size and pathology. For predicting 10 or more metastases, only size and ER-negative status were independent predictors. These factors accounted for less than 20% of the regression, implying that more than 80% of lymph node metastases are not explained by the regression model. Lymph node metastases were seen in 8.3% of T1a, 15.3% of T1b, and 30.7% of T1c lesions.

CONCLUSIONS

Biologic tumor markers are not reliable predictors of lymph node metastasis, except possibly for T1a lesions, therefore direct pathologic evaluation of lymph node status cannot be abandoned. Efforts to determine lymph node status through other methods such as sentinel lymph node biopsy are warranted.