Wide Variation in Surgeons' Attitude Toward Node Dissection

Pam Harrison

July 17, 2018

A survey of surgeons in the United States has found wide variation in their views on the omission of axillary lymph node dissection (ALND) in patients with early breast cancer, even though clinical guidelines now recommend ALND for certain patients.

The survey found that surgeons who perform the most surgeries were the most willing to omit of ALND; those doing the fewest surgeries were the least likely to omit it.

The findings were published online July 12, 2018 in JAMA Oncology.

These results suggest that in many situations, patients are undergoing ALND unnecessarily and thus, in essence, are being overtreated, say the authors, led by Monica Morrow, MD, Memorial Sloan Kettering Cancer Center, New York City.

They recommend that "women with clinically node-negative cancer undergoing breast-conserving treatment with whole-breast irradiation who are advised that ALND is routine for the finding of any senitel node (SN) metastases should seek a second opinion."

In addition, patients should "reserve consent for ALND until final surgical pathologic tests results are available to ensure a complete discussion of the alternatives to ALND when SN metastases are present," they write.

One of the most common complications after ALND is lymphedema. "Patients report that lymphedema is the most-feared long-term consequence of breast cancer treatment," the authors comment. They add that "behaviors adopted to minimize the risk of lymphedema may interfere with employment or negatively affect quality of life."

Details of Survey Findings

The 376 surgeons who took part the survey represented 77% of the 488 surgeons who were invited to participate. A total of 5080 patients with stage I/II cancer were treated between 2013 and 2015 by all surgeons invited to participate.

The survey found that about half of the surgeons surveyed (49%) would "definitely" or "probably" recommend ALND if a woman presented with one SN macrometastasis; almost two thirds (62.6%) would "definitely" or "probably" recommend the procedure if a woman had two SN macrometastases.

This is despite the fact that results from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial, published in 2011, failed to show any benefit.

There was no difference in locoregional recurrence, disease-free survival, or overall survival between women who underwent ALND and those who underwent SN biopsy alone in the setting of clinically node-negative breast cancer with metastases in one or two SNs in women who were treated with breast-conserving surgery plus whole-breast irradiation.

These results were reaffirmed in 2017 when the 10-year outcomes of the same study were published and showed no difference in the same endpoints.

The survey also examined under which circumstances surgeons felt ALND could be omitted and under which circumstances they would not omit it in five clinical scenarios.

The cases presented were typical of inclusion criteria for patients in the ACOSOG Z0011 study, among other trials.

Responses to these scenarios were then used to grade a surgeon's propensity to recommend ALND or not.

Another Question

The survey also explored surgeons attitudes to another recent clinical guideline.

In 2014, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) released guidelines that indicated that the absence of ink on tumor was adequate for determining surgical margins for patients treated with lumpectomy followed by whole-breast irradiation.

In the survey, the investigators examined the association between a surgeon's willingness to accept the SSO-ASTRO recommendation of minimal negative-margin width in the absence of ink on tumor and their willingness not to perform ALND in early breast cancer patients with one or two positive SNs.

ALND Findings

Of the surgeons surveyed, 12.7% indicated they would "probably" recommend ALND for patients with isolated tumor cells or micrometastases in a single SN. Another 12.6% would "definitely" recommend the procedure for the same group of patients.

"Using outer quartiles of the ALND scale values, surgeons were categorized into low...selective...and high...ALND propensity groups," the study authors explain.

Only one surgeon in the low-ALND-propensity group indicated that ALND should "definitely" or "probably" be performed in the presence of any SN macrometastases.

By comparison, 38.6% of surgeons who ranked in the selective-ALND-propensity group and 95.5% of surgeons in the high-ALND-propensity group (P < .001) indicated that ALND should be peformed.

Surgeons were then asked if they would obtain an intraoperative frozen section of the SN; 28.7% of the low-ALND-propensity surgeons indicated that they would.

In contrast, 44.1% of surgeons in the selective-ALND-propensity group and 86.5% of surgeons in the high-ALND-propensity group would recommend obtaining an intraoperative frozen section of the SN (P < .001).

The researchers then matched surgical volume with each propensity group.

Results revealed that 41% of high-volume surgeons who performed more than 50 breast cancer surgeries a year ranked as a low-ALND-propensity surgeon, compared with only 14.3% of surgeons who performed 20 or fewer breast cancer surgeries a year.

"Conversely, 40% of low-volume surgeons had a high propensity for ALND compared with 9% of high-volume surgeons," investigators report.

"Surgeons with a high propensity for ALND were also less likely to accept lumpectomy margins of no ink on tumor," they add.

These results suggest that in many situations, patients are undergoing ALND unnecessarily and so may be overtreated, the authors suggest.

Just as worrisome, the investigators found that 7.8% of surgeons would "definitely" or "probably" omit ALND for macrometastases in three or more SNs in patients undergoing breast-conserving therapy.

"This fact is evidence of undertreatment, as, to our knowledge, no data exist to support the safety of this practice," the authors state.

"Development of an evidence-based, practical guideline outlining acceptable alternatives to ALND in these patient subgroups should be a priority," the researchers conclude.

Surgeons Slow to Embrace Change

In an accompanying editorial, Sara Javid, MD, and Benjamin Anderson, MD, both from the University of Washington in Seattle, point out that surgeons are often slow to embrace changes in standard practice.

One example is the slow adoption of breast conserving therapy in early-stage breast cancer. Five years after a pivotal study showed that breast-conserving therapy was not inferior to mastectomy, only about one third of women in the SEER registry with stage I breast cancer were being treated with recommended surgical techniques.

Similarly, in 2005, the American College of Surgeons supported the use of core needle biopsy over surgical biopsy for diagnosing image-detected breast abnormalities. But even today, surgical breast biopsy rates are as high as 32% nationally in the United States, the editorialists point out.

"What will shift surgeon behavior toward higher quality, evidence-based practices?" Javid and Anderson ask.

One tactic is to make professionals aware of how they measure up relative to their peers.

In one study, for example, researchers showed that adherence to quality metrics increased dramatically once surgeons in a large healthcare system were given individual and system-wide performance results.

"With increased visibility of one's own performance relative to peers and evidence-based standards of practice, combined with the support of a respected credentialing body, such as the American Board of Surgery, toward the delivery and measurement of care, meaningful change is plausible," Javid and Anderson predict.

The study was funded by a grant to the University of Michigan from the National Cancer Institute. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Oncol. Published online July 12, 2018. Full text, Editorial

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