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Is Axillary Lymph Node Dissection Indicated for Early-Stage Breast Cancer? A Decision Analysis

From the Institute of Statistics and Decision Sciences and Center for Clinical Health Policy Research, Duke University; Comprehensive Cancer Center, Department of Surgery, and Department of Radiation Oncology, Duke University Medical Center, Durham, NC; Dana-Farber Cancer Institute, Boston, MA; and National Center for Atmospheric Research, Boulder, CO.

Address reprint request to Giovanni Parmigiani, PhD, Institute of Statistics and Decision Sciences, Box 90251, Duke University, Durham, NC 27708; email gp{at}isds.duke.edu

PURPOSE: Axillary lymph node dissection (ALND) has been a standard procedure in the management of breast cancer. In a patient with a clinically negative axilla, ALND is performed primarily for staging purposes, to guide adjuvant treatment. Recently, the routine use of ALND has been questioned because the results of the procedure may not change the choice of adjuvant systemic therapy and/or the survival benefit of a change in adjuvant therapy would be small. We constructed a decision model to quantify the benefits of ALND for patients eligible for breast-conserving therapy.

METHODS: Patients were grouped by age, tumor size, and estrogen receptor (ER) status. The model uses the Oxford overviews and three combined Cancer and Leukemia Group B studies. We assumed that patients who did not undergo ALND received axillary radiation therapy and that the two procedures are equally effective. All chemotherapy combinations were assumed to be equally efficacious.

RESULTS: The largest benefits from ALND are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-negative women, almost all of whom would receive adjuvant chemotherapy. When adjusted for quality of life (QOL), ALND may have an overall negative impact. In general, the benefits of ALND increase with the expected severity of adjuvant therapy on QOL.

CONCLUSION: Our model quantifies the benefits of ALND and assists decision making by patients and physicians. The results suggest that the routine use of ALND in breast cancer patients should be reassessed and may not be necessary in many patients.

The research in this study was performed when all authors were affiliated with Duke University and supported by grant no. NCI P50 CA68438 from the National Institutes of Health under the Specialized Program of Research Excellence in Breast Cancer and planning grant no. NCI R21-CA68438-01.

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