Abstract
Objective: The application of sentinel lymph node biopsy (SLNB) in elderly patients with early breast cancer remains somewhat controversial. This study aimed to establish individualized nomograms to predict survival outcomes of elderly patients with and without SLNB and find out which patients could avoid SLNB.Methods: A total of 39,962 ≥70-year-old patients diagnosed with T1–T2 breast cancer in 2010–2015 were included from the Surveillance, Epidemiology, and End Results (SEER) program and were divided into the training set (n = 29,971) and the validation set (n = 9,991). Axillary surgery was not specified in the SEER database, and we defined removing one to five lymph nodes as SLNB. Survival analysis was performed using the Kaplan–Meier plot and log-rank test. Multivariate Cox analysis was utilized to identify risk factors for overall survival (OS) and breast-cancer-specific survival (BCSS). Nomograms and a risk stratification model were constructed.Results: In the training set, patients with SLNB had better OS (adjusted HR 0.57, P < 0.001) and BCSS (adjusted HR 0.55, P < 0.001) than patients without SLNB. Multivariate COX analysis identified age, marital status, grade, subtype, T stage, and radiation as independent risk factors for OS and BCSS in both SLNB and non-SLNB groups (all P < 0.05). They were subsequently incorporated to establish nomograms to predict 3- and 5-year OS and BCSS for patients with or without SLNB. The concordance index ranged from 0.687 to 0.820, and calibration curves in the internal set and external set all demonstrated sufficient accuracies and good predictive capabilities. Further, we generated a risk stratification model which indicated that SLNB improved OS and BCSS in high-risk group (OS: HR 0.49, P < 0.001; BCSS: HR 0.54, P < 0.001), but not in the low-risk group (all P > 0.05).Conclusion: Well-validated nomograms and a risk stratification model were constructed to evaluate survival benefit from SLNB in elderly patients with early-stage breast cancer. SLNB was important for patients in the high-risk group but could be omitted in the low-risk group without sacrificing survival. This study could assist clinicians and elderly patients to weigh the risk–benefit of SLNB and make individualized decisions. We look forward to more powerful evidence from prospective trials.
Highlights
The concept of the treatment strategy for breast cancer has shifted from “maximum tolerated therapy” to “minimum effective therapy.” For breast cancer patients, axillary staging is an important part of the surgical process, and sentinel lymph node (SLN) biopsy (SLNB), with satisfactory sensitivity and accuracy, has been established as the standard care for patients with early-stage breast cancer [1]
SLNB is associated with improved quality of life and reduced morbidities compared with axillary lymph node dissection (ALND) [3, 4], a considerable number of patients undergoing SLNB still suffer from arm and shoulder complications, which could be more severe in elderly patients [5, 6]
While earlier studies suggested that SLNB should be offered in elderly patients [9,10,11], several recent studies indicated that elderly patients with early-stage and hormone-positive breast cancer gained limited survival benefit from SLNB resulting in an increasing omission of SLNB in appropriately selected patients [12,13,14]
Summary
The concept of the treatment strategy for breast cancer has shifted from “maximum tolerated therapy” to “minimum effective therapy.” For breast cancer patients, axillary staging is an important part of the surgical process, and sentinel lymph node (SLN) biopsy (SLNB), with satisfactory sensitivity and accuracy, has been established as the standard care for patients with early-stage breast cancer [1]. The role of SLNB in elderly patients with low-risk breast cancer is yet controversial. For elderly patients who often face multiple comorbidities and have a lower tolerance of aggressive treatment than the younger patients, the risk of SLNB must be balanced with the benefit of staging and local control. Several ongoing prospective trials, such as the Sentinel node vs Observation after axillary Ultra-SouND (SOUND) and the Intergroup-SentinelMamma (INSEMA), are evaluating whether SLNB can even be avoided in early breast cancer patients with a negative preoperative axillary assessment (including axillary ultrasound exploration and biopsy for suspicious lymph nodes) [15, 16]. Heretofore, there is a paucity of literature regarding omission of SLNB in elderly women with low-risk breast cancer, and few guidelines have explicitly stated the application of SLNB in the elderly
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