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Original Investigation |

Racial Disparities in Adoption of Axillary Sentinel Lymph Node Biopsy and Lymphedema Risk in Women With Breast Cancer

Dalliah M. Black, MD1; Jing Jiang, MS2; Henry M. Kuerer, MD, PhD1; Thomas A. Buchholz, MD3; Benjamin D. Smith, MD2,3
[+] Author Affiliations
1Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
2Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
3Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
JAMA Surg. 2014;149(8):788-796. doi:10.1001/jamasurg.2014.23.
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Importance  Racial disparities exist in many aspects of breast cancer care. Sentinel lymph node biopsy (SLNB) was developed to replace axillary lymph node dissection (ALND) for staging early breast cancer to minimize complications. Racial disparities in the use of SLNB remain incompletely characterized, and their effect on lymphedema risk is not known.

Objective  To determine racial differences in SLNB use among patients with pathologically node-negative breast cancer during the period when SLNB became the preferred method for axillary staging as well as whether such differences affect lymphedema risk.

Design, Setting, and Participants  A retrospective study was conducted using the Surveillance, Epidemiology, and End Results–Medicare–linked database from 2002 through 2007 to identify cases of incident, nonmetastatic, pathologically node-negative breast cancer in women aged 66 years or older.

Main Outcomes and Measures  Sentinel lymph node biopsy use and 5-year cumulative incidence of lymphedema by race.

Results  Of 31 274 women identified, 1767 (5.6%) were black, 27 856 (89.1%) were white, and 1651 (5.3%) were of other or unknown race. Sentinel lymph node biopsy was performed in 73.7% of white patients and 62.4% of black patients (P < .001). The use of SLNB increased by year for both black and white patients (P < .001); however, a fixed disparity of approximately 12 percentage points in SLNB use persisted through 2007. In adjusted analysis, black patients were significantly less likely than white patients to undergo SLNB (odds ratio, 0.67; 95% CI, 0.60-0.75; P < .001). Overall, the 5-year cumulative lymphedema risk was 8.2% in whites and 12.3% in blacks (hazard ratio [HR], 1.43; 95% CI, 1.23-1.67; P < .001). When stratified by type of axillary surgery, 5-year lymphedema risk was 6.8% in whites undergoing SLNB (HR, 1 [reference]), 8.8% in blacks undergoing SLNB (HR, 1.28; 95% CI, 1.02-1.60; P = .03), 12.2% in whites undergoing ALND (1.79; 1.63-1.96; P < .001), and 18.0% in blacks undergoing ALND (2.76; 2.25-3.39; P < .001).

Conclusions and Relevance  Although SLNB use increased in both black and white patients with pathologically node-negative breast cancer from 2002 through 2007, the rates of SLNB remained lower in black than white patients during this entire period by approximately 12 percentage points. This racial disparity in SLNB use contributed to racial disparities in lymphedema risk. Improvements in the dissemination of new techniques are needed to avoid disparities in breast cancer care and patient outcomes, particularly in disadvantaged groups.

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Figure 1.
Change in Use of Sentinel Lymph Node Biopsy (SLNB) Over Time

The proportion of patients undergoing SLNB is reported using the composite definition of both Surveillance, Epidemiology, and End Results (SEER) registrar coding and Medicare procedure claims (A), a definition derived only from Medicare claims (B), and a definition derived only from SEER registrar coding (C). Limit lines indicate 95% CIs. There was a significant difference in the use of SLNB for whites vs blacks regardless of the definition (all P < .001).

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Figure 2.
Cumulative Incidence of Lymphedema Diagnosis Code by Race and Type of Axillary Surgery

Cumulative incidence of lymphedema, defined by the presence of a diagnosis code indicating lymphedema, was calculated using the Kaplan-Meier method and stratified by race and type of axillary surgery. Differences across the strata were statistically significant (P < .001). ALND indicates axillary lymph node dissection; SLNB, sentinel lymph node biopsy.

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