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Research Letter |

Not Performing a Sentinel Node Biopsy for Older Patients With Early-Stage Invasive Breast Cancer FREE

Alice Chung, MD1,2; Alexandra Gangi, MD1,2; Farin Amersi, MD1,2; Xiao Zhang, PhD3; Armando Giuliano, MD1,2
[+] Author Affiliations
1Division of Surgical Oncology, Cedars-Sinai Medical Center, Los Angeles, California
2Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
3Department of Statistics, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles
JAMA Surg. 2015;150(7):683-684. doi:10.1001/jamasurg.2015.0647.
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Published online

Axillary surgery contributes to morbidity and has not been shown to improve survival in early breast cancer. Women 70 years of age or older with clinically node-negative breast cancer are more likely to have comorbidities and reduced life expectancy, and there is controversy as to whether or not a sentinel node biopsy is warranted in this population. The purpose of our study was to evaluate the safety of not performing a sentinel node biopsy for patients 70 years of age or older with clinically node-negative breast cancer.

With institutional review board approval from Cedars-Sinai Medical Center, a review of a prospectively maintained database from January 1, 2000, to December 31, 2011, identified 140 women 70 years of age or older with clinical T1-2N0 breast cancer who underwent breast-conserving surgery without a sentinel node biopsy at our institution. Informed consent was not obtained because the data were de-identified. The clinicopathological characteristics were documented: age at diagnosis, tumor size, histology, grade, estrogen receptor (ER) and progesterone receptor (PR) status, HER2 status, and adjuvant therapy received (radiation, chemotherapy, or hormonal therapy). Locoregional recurrence, breast cancer–specific survival, overall survival, and causes of death were determined. Statistical analysis (χ2 test and log-rank test) was performed to characterize the study population and determine predictors of overall survival.

Among 140 patients, the median age was 83 years (range, 70-97 years). Tumors were more frequently T1 (74%) than T2 (26%) tumors (P < .001), were more frequently grade 2 (62 patients [44%]) than grade 1 (38 patients [27%]) or grade 3 (40 patients [29%]) (P = .03), were more frequently positive (86%) than negative for ER (14%) (P < .001), were more frequently positive (73%) than negative for PR (27%) (P < .001), were more frequently negative (92%) than positive for HER2 (8%) (P < .001), and were more frequently of ductal histology (65%) than any other histology (35%) (P < .001). More patients did not receive than did receive chemotherapy (98% vs 2%; P < .001), radiation (76% vs 24%; P < .001), or hormonal therapy (59% vs 41%; P = .04). The median follow-up period was 4.5 years. Of 140 patients, 5 (4%) experienced a breast cancer–related event: 1 experienced an axillary recurrence (tumor was negative for ER, PR, and HER2), and 4 patients died of breast cancer (2 patients were negative for ER, PR, and HER2; 1 patient was negative for ER and HER2 and positive for PR; and 1 patient was positive for ER and HER2 and negative for PR). The 5-year overall survival rate was 70%, and the 5-year breast cancer–specific survival rate was 96% (Figure). The most common cause of death was ischemic heart disease. Tumor size was the only factor that correlated with survival.

Place holder to copy figure label and caption
Figure.
Kaplan-Meier Survival Estimates
Graphic Jump Location

Patients with breast cancer who are 70 years of age or older present challenges in treatment as physicians aim to optimize therapy while accounting for life expectancy, comorbidities, and the effects of treatment on function. Women 70 to 74 years of age with breast cancer have, on average, 3 comorbidities, and for women 75 to 84 years of age, this number increases to 4.1 In addition, 85% of patients with node-negative breast cancer who are 70 years of age or older and 65% of patients with node-positive breast cancer who are 70 years of age or older die of causes unrelated to breast cancer.1 In this age group, survival is not dependent on nodal tumor burden, and a sentinel node biopsy carries morbidity that may be unnecessary.

Our study demonstrated low axillary recurrence and low mortality for patients with clinical T1-2N0 breast cancer who were 70 years of age or older and who underwent breast-conserving surgery without a sentinel node biopsy. Several randomized trials25 have demonstrated that the extent of axillary surgery does not influence survival among clinically node-negative patients. While axillary lymph node dissection has been omitted as a standard of care for appropriately selected patients undergoing breast-conserving surgery, a sentinel node biopsy is still relied on to determine prognosis and guide treatment. As adjuvant therapy becomes increasingly guided by genomics, the use of a sentinel node biopsy may be questioned. Early operable breast cancer in older patients tends to be positive for ER, emphasizing the importance of hormonal therapy.6 Our patient population was largely positive for ER, but only 40% received hormonal therapy. Despite this, only 4% of patients experienced a breast cancer–related event.

Not performing a sentinel node biopsy may avoid potential morbidity and should be reevaluated for patients 70 years of age or older with clinically negative nodes. Patients were unlikely to have treatment recommendations changed based on a sentinel node biopsy, and adjuvant therapy was less likely to be administered, regardless of nodal status. Patients in this subgroup were more likely to die of causes other than breast cancer, and not performing a sentinel node biopsy did not affect survival.

Corresponding Author: Alice Chung, MD, Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, 310 N San Vicente Blvd, 3rd Floor, Los Angeles, CA 90048 (alice.chung@cshs.org).

Published Online: May 27, 2015. doi:10.1001/jamasurg.2015.0647.

Author Contributions: Drs Chung and Gangi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chung, Giuliano.

Acquisition, analysis, or interpretation of data: Chung, Gangi, Amersi, Zhang.

Drafting of the manuscript: Chung, Gangi, Zhang, Giuliano.

Critical revision of the manuscript for important intellectual content: Chung, Amersi, Giuliano.

Statistical analysis: Zhang.

Obtained funding: Gangi, Giuliano.

Administrative, technical, or material support: Chung, Amersi, Giuliano.

Conflict of Interest Disclosures: None reported.

Funding/Support: The collection, management, and analysis of data for this work was supported by the Margie and Robert E. Petersen Foundation and the Fashion Footwear Charitable Foundation of New York.

Role of the Funder/Sponsor: The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Jones  EL, Leak  A, Muss  HB.  Adjuvant therapy of breast cancer in women 70 years of age and older: tough decisions, high stakes. Oncology (Williston Park). 2012;26(9):793-801.
PubMed
Rudenstam  CM, Zahrieh  D, Forbes  JF,  et al; International Breast Cancer Study Group.  Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10-93. J Clin Oncol. 2006;24(3):337-344.
PubMed   |  Link to Article
Martelli  G, Boracchi  P, De Palo  M,  et al.  A randomized trial comparing axillary dissection to no axillary dissection in older patients with T1N0 breast cancer: results after 5 years of follow-up. Ann Surg. 2005;242(1):1-6.
PubMed   |  Link to Article
Fisher  B, Jeong  JH, Anderson  S, Bryant  J, Fisher  ER, Wolmark  N.  Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347(8):567-575.
PubMed   |  Link to Article
Veronesi  U, Orecchia  R, Zurrida  S,  et al.  Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy. Ann Oncol. 2005;16(3):383-388.
PubMed   |  Link to Article
Hind  D, Wyld  L, Beverley  CB, Reed  MW.  Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev. 2006;(1):CD004272.
PubMed

Figures

Place holder to copy figure label and caption
Figure.
Kaplan-Meier Survival Estimates
Graphic Jump Location

Tables

References

Jones  EL, Leak  A, Muss  HB.  Adjuvant therapy of breast cancer in women 70 years of age and older: tough decisions, high stakes. Oncology (Williston Park). 2012;26(9):793-801.
PubMed
Rudenstam  CM, Zahrieh  D, Forbes  JF,  et al; International Breast Cancer Study Group.  Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10-93. J Clin Oncol. 2006;24(3):337-344.
PubMed   |  Link to Article
Martelli  G, Boracchi  P, De Palo  M,  et al.  A randomized trial comparing axillary dissection to no axillary dissection in older patients with T1N0 breast cancer: results after 5 years of follow-up. Ann Surg. 2005;242(1):1-6.
PubMed   |  Link to Article
Fisher  B, Jeong  JH, Anderson  S, Bryant  J, Fisher  ER, Wolmark  N.  Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347(8):567-575.
PubMed   |  Link to Article
Veronesi  U, Orecchia  R, Zurrida  S,  et al.  Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy. Ann Oncol. 2005;16(3):383-388.
PubMed   |  Link to Article
Hind  D, Wyld  L, Beverley  CB, Reed  MW.  Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev. 2006;(1):CD004272.
PubMed

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