British women's choice between sentinel node biopsy and axillary node clearance for breast cancer

Patient-reported outcomes in sentinel node-negative adjuvant breast cancer patients receiving sentinel-node biopsy or axillary dissection: National Surgical Adjuvant Breast and Bowel Project phase III protocol B-32

PURPOSE

Sentinel lymph node resection (SNR) may reduce morbidity while providing the same clinical utility as conventional axillary dissection (AD). National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 is a randomized phase III trial comparing SNR immediately followed by AD (SNAD) to SNR and subsequent AD if SN is positive. We report the definitive patient-reported outcomes (PRO) comparisons.

PATIENTS AND METHODS

Eligible patients had clinically node-negative, operable invasive breast cancer. The PRO substudy included all SN-negative participants enrolled May 2001 to February 2004 at community institutions in the United States (n = 749; 78% age > or = 50; 87% clinical tumor size < or = 2.0 cm; 84% lumpectomy; 87% white). They completed questionnaires presurgery, 1 and 2 to 3 weeks postoperatively, and every 6 months through year 3. Arm symptoms, arm use avoidance, activity limitations, and quality of life (QOL) were compared with intent-to-treat two-sample t-tests and repeated measures analyses.

RESULTS

Arm symptoms were significantly more bothersome for SNAD compared with SNR patients at 6 months (mean, 4.8 v 3.0; P < .001) and at 12 months (3.6 v 2.5; P = .006). Longitudinally, SNAD patients were more likely to experience ipsilateral arm and breast symptoms, restricted work and social activity, and impaired QOL (P < or = .002 all items). From 12 to 36 months, fewer than 15% of either SNAD or SNR patients reported moderate or greater severity of any given symptom or activity limitation.

CONCLUSION

Arm morbidity was greater with SNAD than with SNR. Despite considerable fears about complications from AD for breast cancer, this study demonstrates that initial problems with either surgery resolve over time.

Late morbidity associated with a tumour-negative sentinel lymph node biopsy in primary breast cancer patients: a systematic review

AIMS

To evaluate the relationship between late morbidity (i.e. > or =6 months) and a tumour-negative sentinel lymph node biopsy (SLNB) in primary breast cancer patients by using a systematic review approach, and to identify the predictors of late morbidity.

METHODS

We performed a systematic review of the literature for studies concerning the late morbidity of patients who had undergone SLNB alone or SLNB followed by ALND when SLN metastases were found. A literature search over the last 16 years (1993-2008) was performed in the databases MEDLINE and EMBASE. The methodological quality of the selected studies was assessed according to a list of predefined criteria. The data of assessment and predictors of late morbidity were collected.

RESULTS

We identified a total of 32 papers reporting 27 independent cohort studies, of which 17 were high quality studies and were further analysed in this review. There was a great variation in the prevalence of pain (7.5-36%), impairment of range of motion (0.0-31.0%), oedema (0.0-14.0%), decreased strength (11.0-19.0%) and sensory disorders (1.0-66.0%). Factors such as time after surgery and young age were strong predictors of late morbidity. Breast surgery, radiation to axilla, tumour location, body mass index (BMI) and two-step procedure, especially lymph mapping techniques, could also predict the late morbidity to different extents.

CONCLUSIONS

SLNB-associated late morbidity, even with a low prevalence, remains a clinical problem which cannot be neglected in primary breast cancer patients. Time after surgery and young age are the important predictors for late morbidity in primary breast cancer patients after SLNB; breast surgery, radiation to axilla, tumour location, BMI and two-step procedure also have limited prognostic value.

Morbidity comparison of sentinel lymph node biopsy versus conventional axillary lymph node dissection for breast cancer patients: Results of the sentinella–GIVOM Italian randomised clinical trial

AIMS

To compare physical morbidity and health-related quality of life (HRQOL) in breast cancer patients who received standard axillary dissection (ALND) or sentinel lymph node biopsy (SLNB), followed by axillary dissection only in the case of sentinel-node positivity, within a randomised clinical trial.

PATIENTS AND METHODS

Patients with early breast cancer < or =3cm and clinically negative axilla were randomly allocated to ALND or SLNB. All patients underwent physical examination every 6 months in order to assess any arm-related symptoms. A subset of patients completed the SF-36 quality of life questionnaire and the Psychological General Well Being Index (PGWBI) before randomisation, at 6 and 12 months after surgery and yearly thereafter. Results of the first 24 months are reported.

RESULTS

Six-hundred and seventy-seven patients were available for analysis: 341 patients randomised to the ALND group and 336 to the SLNB group. Six months after surgery, the SLNB group had significantly less lymph-oedema, movement restrictions, pain and numbness with respect to the ALND group. Lymph-oedema was also significantly reduced at 12 months and numbness remained significantly less frequent in the SLNB arm at all time points. Three-hundred and ten patients participated in the HRQOL assessment. The mean scores of the PGWB questionnaire general index and anxiety domain were significantly better in the SLNB group than in the ALND group but the difference ceased to be significant at 24 months.

CONCLUSIONS

The SLNB is associated with reduced arm morbidity without evidence of a negative impact on psychological well being. While waiting for long-term results of ongoing randomised clinical trials, the SLNB may be proposed for early stage breast cancer patients after adequate information on the expected advantages and the possible risks.

A prospective study of use of a clinicopathological score to select patients for the type of axillary surgery

AIMS

The aim of this study was to prospectively assess a previously described and independently validated clinicopathological score for counselling and selecting patients for sentinel node biopsy or axillary clearance. The clinicopathological score is based on the size of primary tumour, grade of primary tumour, age of the patient, quadrant of the breast and lymphovascular invasion, which are all independent predictors of lymph node involvement. The clinicopathological score may assist patients to decide if they would benefit from sentinel node biopsy or axillary clearance as a primary procedure.

METHODS

All patients with invasive breast cancer were counselled for the possible rate of lymph node positivity, need for a second operation and false negative rate for sentinel node biopsy. Based on a previously validated clinicopathological score (Table 1), patients with a score of 10 or below were classed as less likely to have positive lymph nodes and hence were offered for minimally invasive axillary surgery and patients with a score of 11 or above were regarded to have high risk of nodal involvement and were counselled for axillary clearance.

RESULTS

Only 3 of 31 patients in the low score group had axillary metastasis and needed further axillary treatment. The node positivity rate in the low score group was 10% compared to 63% for the high score group.

CONCLUSION

It is concluded that until pre-operative axillary staging becomes widely available, by using the clinicopathological score for patient's selection for minimally invasive axillary surgery, it may be possible to avoid a second axillary procedure in a large majority of patients.

Surmounting the challenges of sentinel lymph node biopsy for breast cancer in non-tertiary centres and community-based practices

BACKGROUND

Sentinel lymph node biopsy (SLNB), a procedure associated with low morbidity, has been shown to be an accurate technique for determining axillary lymph node status in breast cancer. It is now a standard of care in many tertiary oncology centres. The purpose of this study was to determine the feasibility of carrying out SLNB in non-tertiary centres and community practices without full nuclear medicine facilities and lower patient volume.

METHODS

From November 2002 to February 2005, 50 women diagnosed with clinically node-negative breast cancer underwent 52 sentinel lymph node procedures. Surgery was carried out in five hospitals with different access to nuclear medicine facilities. Lymphatic mapping was therefore carried out with blue dye only. Patients were divided into two groups: group 1 comprised those with invasive disease who went on to have an axillary clearance, and group 2 comprised those who underwent SLNB only for a negative node. Routine pathological examination was carried out for sentinel nodes.

RESULTS

There were 31 SLNB with axillary dissection and 21 SLNB only. The identification rate was 96.2%. Among those who had concomitant axillary dissection, there were no false-negative results. The overall accuracy was 94%, sensitivity was 82% and specificity was 100%.

CONCLUSION

Consistent results in non-tertiary centres can be achieved with adequate attention to appropriate preceptorship and meticulous technique. Women who elect to have surgical treatment for breast cancer in these hospitals need not be denied the benefits of SLNB.

A clinicopathological scoring system to select breast cancer patients for sentinel node biopsy

BACKGROUND

Selecting patients for sentinel node biopsy, based on grade and size of the primary tumour, often results in the need for a second operation of axillary clearance since intra-operative pathological assessment of sentinel node is in its evolution at present. It may be possible to refine the clinical criteria to select patients for the type of axillary surgery.

AIM

By using a score based on clinicopathological predictors of axillary lymph node involvement, we hypothesise that it may be possible to identify patients at high or low risk of nodal involvement. This information can be used to assist patients to make informed decision regarding risks and benefits of sentinel node biopsy or axillary clearance.

PATIENTS AND METHODS

A score was devised based on the clinicopathological variables of 113 patients to assess the likelihood of lymph node positivity. This score was validated on an independent data set of 89 patients who underwent sentinel node biopsy and axillary surgery. Based on the score, patients were divided into two groups, high score and low score groups. For the low score group, lymph node positivity was 18% for the original score and 24% for the validation score. Lymph node positivity rate was 67% for the high score group for the original series and 65% for the validation series of patients.

CONCLUSION

A clinicopathological scoring system can assist in selecting patients with breast cancer for sentinel node biopsy.

Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer

This study is the first large prospective RCT of sentinel node biopsy (SNB) compared with standard axillary treatment (level I-III axillary lymph node dissection or four node sampling), which includes comprehensive and repeated quality of life (QOL) assessments over 18 months. Patients (n = 829) completed the Functional Assessment of Cancer Therapy - Breast (FACT-B+4) and the Spielberger State/Trait Anxiety Inventory (STAI) at baseline (pre-surgery) and at 1, 3, 6, 12, and 18 months post-surgery. There were significant differences between treatment groups favouring the SNB group throughout the 18 months assessment. Patients in the standard treatment group showed a greater decline in Trial Outcome Index (TOI) scores (physical well-being, functional well-being and breast cancer concerns subscales in FACT-B+4) and recovered more slowly than patients in the SNB group (p < 0.01). The change in total FACT-B+4 scores (measuring global QOL) closely resembled the TOI results. 18 months post-surgery approximately twice as many patients in the standard group compared with the SNB group reported substantial arm swelling (14% versus 7%) (p = 0.002) or numbness (19% versus 8.7%) (p < 0.001). Despite the uncertainty about undergoing a relatively new procedure and the possible need for further surgery, there was no evidence of increased anxiety amongst patients randomised to SNB (p > 0.05). For 6 months post-surgery younger patients reported less favourable QOL scores (p < 0.001) and greater levels of anxiety (p < 0.01). In view of the benefits regarding arm functioning and quality of life, the data from this randomised study support the use of SNB in patients with clinically node negative breast cancer.