Patterns of Axillary Surgical Care for Breast Cancer in the Era of Sentinel Lymph Node Biopsy

Population-based overall patterns of surgical management of the axilla in women with operable breast cancer during the era of adoption of sentinel lymph node biopsy (SLNB) were studied. Women with operable breast carcinoma residing in 14 geographic areas of the Surveillance, Epidemiology, and End Results (SEER) cancer registries (1998-2004, n = 239,661) were assessed for axillary surgical patterns of care. Use of SLNB increased from 11 to 59%. Use of no axillary surgery decreased from 14 to 6.6%. In pathologic node-negative women, use of axillary lymph node dissection (ALND) decreased from 94 to 36%. Independent factors most associated with failure to receive SLNB included diagnosis year (2000: 62%; 2004: 29%), surgery (mastectomy: 64%; breast-conserving surgery: 36%), tumor size (T3: 71%; T2: 56%; T1: 40%), age (a parts per thousand yen70 years: 50%; < 70 years: 45%), grade (high: 42%; low: 38%), urbanity (non-large metropolitan area: 49%; large metropolitan area: 42%), and, by quartile, poverty (highest: 47%; lowest: 35%), and white-collar employment (lowest: 56%; highest: 47%). In pathologic node-positive women who had SLNB, failure to undergo completion ALND increased from 20% in 1998 to 32% in 2004. Patients with smaller, lower-grade tumors, and those with smaller size of nodal metastasis, lack of extracapsular extension, age a parts per thousand yen70 years, increased linguistic isolation, African-American or Hispanic race/ethnicity, and white-collar employment were less likely to undergo completion ALND. Management of the axilla changed dramatically during the period of rapid adoption of SLNB. Patterns of care suggest both appropriate and inappropriate selection for SLNB and ALND.