Too many patients are undergoing axillary lymph node evaluation with breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) of the breast, according to a new retrospective database analysis of records from more than 35,000 women.1 The study was published online in JAMA Oncology.
“Despite guidelines recommending against axillary lymph node evaluation in women with DCIS undergoing BCS and uncertainty regarding its use with mastectomy, [sentinel lymph node biopsy (SLNB)] and [axillary lymph node dissection (ALND)] is performed frequently,” reported lead study author Ellie Coromilas, BA, of Columbia University in New York, NY, and colleagues.
“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.”
The authors reviewed billing-code medical records in the Perspective database for 35,591 women diagnosed with DCIS and who underwent BCS or mastectomy between 2006 and 2012.1
Approximately 75% underwent BCS; 25% underwent mastectomy. Nearly 18% of women receiving BCS underwent either SLNB or ALND, compared to 63% of patients undergoing mastectomy, the researchers reported.1
Women undergoing mastectomy received axillary evaluation at higher rates over time (57% in 2006 to 67% in 2012), whereas rates of axillary evaluation remained stable over time among patients undergoing BCS (16%-18%).1
“It is surprising that even as late as 2012, 11% of women underwent ALND,” commented Kimberly J. Van Zee, MD, of Memorial Sloan Kettering Cancer Center in New York, NY, in a companion essay published with the new study.2
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Widespread breast cancer screening has led to an order-of-magnitude jump in rates of detection for DCIS over recent years—from 2% to 20% of all diagnosed breast cancer cases—noted Dr. Van Zee.2
The value of lymph node evaluation in these cases has been a matter of controversy and varied practices3,4; a separate study published online in The Breast found that the risk of axillary sentinel lymph node involvement in core needle biopsy–detected DCIS is “extremely low,” and that SLNB is unwarranted in such cases when patients are undergoing BCS.4