Abstract
BackgroundSurvival in elderly patients undergoing sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has not been specifically analyzed. This study aimed to explore the association between different types of axillary lymph node (ALN) evaluations and survival of elderly breast cancer patients.MethodsA retrospective cohort study was conducted of invasive ductal breast cancer patients 70 years and older in the Surveillance, Epidemiology, and End Results database (2004–2016). Analyses were performed to compare the characteristics and survival outcomes of patients who received surgical lymph node dissection and those who did not. Breast cancer specific survival (BCSS) and overall survival were compared by using Cox proportional hazards regression analysis and propensity score matching (PSM) methods to account for selection bias from covariate imbalance.ResultsOf the 75,950 patients analyzed, patients without ALN evaluation had a significantly worse prognosis, while there was no significant difference for BCSS between using a sentinel lymph node biopsy (SLNB) and an axillary lymph node dissection (ALND) after adjustment for known covariates [adjusted hazard ratio (HR) = 0.991, 95% confidence interval (CI) = 0.925–1.062, p = 0.800]. In the stratification analyses after PSM, the ALND did not show a significant BCSS advantage compared with SLNB in any subgroups except for the pN1 stage or above. Furthermore, after PSM of the pN1 stage patients, SLNB was associated with a significantly worse BCSS in hormone receptor negative (HR−) patients (HR = 1.536, 95%CI = 1.213–1.946, p < 0.001), but not in the hormone receptor positive (HR+) group (HR = 1.150, 95%CI = 0.986–1.340, p = 0.075).ConclusionIn our study, ALND does not yield superior survival compared with SLNB for elderly patients with pN1 stage HR+ breast cancer. Although our findings are limited by the bias associated with retrospective study design, we believe that in the absence of results from randomized clinical trials, our findings should be considered when recommending the omission of ALND for elderly breast cancer patients.
Highlights
Since the early 2000s surgical techniques for axillary treatment and staging of patients with primary breast cancer have become less extensive and more focused on minimizing the risk related to surgery [1]
In the era of precision medicine, our study aimed to explore the association between different types of axillary lymph node evaluations with survival and provide new insight into axillary management for elderly breast cancer patients
We further evaluated whether the breast cancer specific survival (BCSS) advantage of axillary lymph node dissection (ALND) still existed when considering different numbers of positive lymph nodes or different hormone receptor status (Figures 3C–E)
Summary
Since the early 2000s surgical techniques for axillary treatment and staging of patients with primary breast cancer have become less extensive and more focused on minimizing the risk related to surgery [1]. Since no survival improvement with ALND was identified in relevant studies [5, 6], the Society of Surgical Oncology Choosing Wisely Guidelines recommended in 2016 that surgeons “do not routinely use sentinel node biopsy in clinically node-negative women ≥70 years of age with hormone receptor-positive (HR+) invasive breast cancer”. This recommendation aroused extensive discussion [7,8,9] about whether cN0 elderly breast cancer patients can be exempted from axillary lymph node evaluation. This study aimed to explore the association between different types of axillary lymph node (ALN) evaluations and survival of elderly breast cancer patients
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