Is Information from Axillary Dissection Relevant to Patients with Clinically Node-Negative Breast Cancer?

The changing trends in the diagnosis and management of women with invasive breast cancer have prompted an examination of the need for routine axillary lymph node dissection (ALND) in women with a clinically negative axilla. The objective of this study was to examine the value of information from an ALND in guiding the selection of adjuvant systemic therapy for women with clinically node-negative breast cancer. Between January 1996 and June 2000, 447 clinically node-negative women underwent an ALND as part of their treatment for invasive breast cancer at Westmead Hospital. Three categories of risk of recurrence were devised, based on the primary tumor characteristics alone, without information from an ALND. Recommendations for adjuvant systemic therapy with and without information from an ALND were compared, and the frequency of change was calculated. Overall, 12% of women had their treatment recommendation altered by their pathologic nodal status based on the model treatment algorithm. For women in the low-risk category (pathologic tumor size ≤ 10 mm, grade 1, lymphovascular invasion [LVI] negative, and estrogen receptor [ER] positive)1, 17% of those less than 50 years old and 14% of those 50-69 years old would have a shift in their treatment recommendations based on the pathologic nodal status. In addition, 13% of the women less than 50 years old and 10% of those 50-69 years old were recommended for more intensive chemotherapy on the basis of four or more involved nodes. For women in the high-risk category (pathologic tumor size greater than 20 mm or greater than 10 mm associated with any unfavorable prognostic factor [grade 3, LVI, or negative ER]), 19% of those less than 50 years old and 18% of those 50-69 years old were recommended for more intensive chemotherapy. Information from ALND did not alter the treatment recommendation for women ≥ 70 years old, as they were not recommended chemotherapy in the model algorithm. If women ≥ 70 years old who were node positive and had an ER-negative tumor were recommended chemotherapy, 14% in the high-risk category would have had their treatment recommendation altered as a result of the information from ALND. The continued utilization of ALND is appropriate in women less than 70 years old in the high-risk category. In other patients less than 70 years old, the pathologic nodal status is of value in guiding the selection of women for adjuvant systemic therapy. For women ≥ 70 years old, information from an ALND adds little to the selection of patients for adjuvant systemic therapy. However, in selected patients ≥ 70 years old who are classified as high risk on the basis of unfavorable primary tumor features, and are potential candidates for chemotherapy, an ALND would be appropriate.