Surgeon Specialization and Use of Sentinel Lymph Node Biopsy for Breast Cancer

Tina W. F. Yen, MD, MS1; Purushuttom W. Laud, PhD2; Rodney A. Sparapani, PhD2; Ann B. Nattinger, MD, MPH3
[+] Author Affiliations
1Division of Surgical Oncology, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
2Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
3Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
JAMA Surg. 2014;149(2):185-192. doi:10.1001/jamasurg.2013.4350.
Text Size: A A A
Published online

Importance  Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema.

Objective  To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon’s operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer.

Design, Setting, and Population  A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined.

Main Outcome and Measure  Type of axillary surgery performed.

Results  Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB.

Conclusions and Relevance  Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours


Place holder to copy figure label and caption
Figure 1.
Distribution of Surgeon Volume and Percentage of Breast Cancer Cases

A, Surgeon volume. B, Surgeon percentage; 2 surgeons with a percentage greater than 60% were excluded. The sum of the first 4 percentages (24%, 30%, 17%, and 8%) shows that 79% of surgeons performed less than 10% of their operative cases for treatment of breast cancer. The remaining 21% of surgeons performed 10% or more of their operative cases for treatment of breast cancer.aPercentage values less than 1%.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Relationship Between Surgeon Volume, Surgeon Percentage, and the Odds Ratio (OR) of Undergoing Sentinel Lymph Node Biopsy (SLNB) vs Axillary Lymph Node Dissection (ALND)

Annual Medicare surgeon volume and the OR of undergoing SLNB vs ALND are depicted relative to the baseline odds of undergoing SLNB for a surgeon who performed 6 annual incident Medicare breast cancer operations and 3% of all surgical procedures for treatment of breast cancer. At each of the surgeon volumes (6, 12, and 24 cases), 4 surgeon percentages are shown. For each box, the black line represents the OR estimate, the box represents the 50% CI, and the vertical error bars represent the 95% CI.

Graphic Jump Location




Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles