Nocera Nadia F, Pyfer Bryan J, De La Cruz Lucy M, Chatterjee Abhishek, Thiruchelvam Paul T, Fisher Carla S
Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Division of Plastic, Maxillofacial and Oral Surgery, Duke University Hospital, Durham, North Carolina.
J Surg Educ. 2018 Sep-Oct;75(5):1281-1286. doi: 10.1016/j.jsurg.2018.02.020. Epub 2018 Mar 28.
Management of the axilla in invasive breast cancer (IBC) has shifted away from more radical surgery such as axillary lymph node dissection (ALND), towards less invasive procedures, such as sentinel lymph node biopsy. Because of this shift, we hypothesize that there has been a national downward trend in ALND procedures, subsequently impacting surgical trainee exposure to this procedure using the ACS-NSQIP database to evaluate this.
Women with IBC were identified in the ACS-NSQIP database from 2007 to 2014. Procedures including ALND were identified using CPT codes. This number was divided by total cases, given a varying number of participating institutions each year. Next, cases involving resident participation were identified and divided by training level: junior (post graduate year-[PGY] 1-2), senior (PGY 3-5) and fellow (PGY ≥ 6). Two tailed z tests were used to compare proportions, with significance determined when p < 0.05.
A total of 128,372 women were identified with IBC with 36,844 ALND. ALND rates decreased by an average of 2.43% yearly from 2007 to 2014. Resident participation significantly drops in 2011, from 49.3% before to 29.4% after (p < 0.01). Junior residents experienced a significant decrease in participation rate (43.3%-32.2%, p < 0.05). Senior residents and fellows experienced an upward trend in their participation, although not significant (51.2%-56.3%, p = 0.35, and 5.6%-11.6%, p = 0.056, respectively).
Using the ACS-NSQIP database, we demonstrate the downward trend in rate of ALND for IBC with subsequent decrease in resident participation. Junior residents experienced a significant decrease in their participation with no significant change for senior or fellow-level trainees. Awareness of this trend is important when creating future surgical curriculum changes for general surgery and fellowship training programs.
浸润性乳腺癌（IBC）腋窝的处理方式已从诸如腋窝淋巴结清扫术（ALND）等更为激进的手术，转向诸如前哨淋巴结活检等侵入性较小的手术。由于这种转变，我们推测全国范围内ALND手术呈下降趋势，随后使用美国外科医师学会国家外科质量改进计划（ACS - NSQIP）数据库对此进行评估，以了解其对外科实习医生接触该手术的影响。
在ACS - NSQIP数据库中识别出2007年至2014年患有IBC的女性。使用现行程序编码（CPT）识别包括ALND在内的手术。该数字除以总病例数，鉴于每年参与机构数量不同。接下来，识别出涉及住院医生参与的病例，并按培训水平进行划分：初级（研究生第1 - 2年[PGY]）、高级（PGY 3 - 5）和专科住院医生（PGY≥6）。使用双尾z检验比较比例，当p < 0.05时确定具有统计学意义。
共识别出128,372例患有IBC的女性，其中36,844例行ALND。从2007年到2014年，ALND率平均每年下降2.43%。2011年住院医生的参与率显著下降，从之前的49.3%降至之后的29.4%（p < 0.01）。初级住院医生的参与率显著下降（从43.3%降至32.2%，p < 0.05）。高级住院医生和专科住院医生的参与率呈上升趋势，尽管不显著（分别从51.2%升至56.3%，p = 0.35，以及从5.6%升至11.6%，p = 0.056）。
使用ACS - NSQIP数据库，我们证明了IBC的ALND率呈下降趋势，随后住院医生的参与率也下降。初级住院医生的参与率显著下降，而高级或专科住院医生水平的实习生则无显著变化。在为普通外科和专科培训项目制定未来手术课程改革时，了解这一趋势很重要。
