Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.
Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
J Surg Res. 2020 Oct;254:31-40. doi: 10.1016/j.jss.2020.03.063. Epub 2020 May 11.
Clinical trials have long established the long-term safety of omitting axillary lymph node dissection (ALND) after sentinel lymph node dissection (SLND) in patients with clinically node-negative early stage breast cancer. The variations in utilization of SLND and ALND in this patient population, however, are currently unknown.
Adult female patients (40 years and older) within the National Cancer Database diagnosed with breast cancer between January 2013 and December 2015, who had clinical T1-T2 and N0 disease, and who underwent either SLND (with or without subsequent ALND) or ALND were included. Differences in utilization across race, ethnicity, insurance type, facility, and residential characteristics were assessed using multivariable logistic regression.
Overall, 271,689 patients were included, of which 26,527 (10%) received ALND and 245,162 (90%) underwent SLND. After adjusting for demographics and cancer characteristics, black (odds ratio [OR], 1.11; 95% confidence interval [95% CI], 1.06-1.17) and Hispanic women (OR, 1.16; 95% CI, 1.10-1.24) were more likely to receive ALND. Patients without health insurance (OR, 1.33; 95% CI, 1.19-1.47), compared with private health insurance, and those receiving treatment at community cancer centers (OR, 1.60; 95% CI, 1.53-1.67), compared with academic/research centers, were also more likely to receive ALND.
Although the vast majority of women undergo SLND, significant disparities exist in its utilization for early stage breast cancer, with traditionally underserved patients receiving unwarranted extensive axillary surgery. Increased patient and surgeon education is needed to decrease variations in care that can affect patient's quality of life.
临床研究长期以来证实，对于临床淋巴结阴性的早期乳腺癌患者，在进行前哨淋巴结活检（SLND）后，省略腋窝淋巴结清扫术（ALND）是安全的。然而，目前尚不清楚在这一患者群体中 SLND 和 ALND 的应用变化情况。
本研究纳入了 2013 年 1 月至 2015 年 12 月期间在国家癌症数据库中诊断为乳腺癌的成年女性患者（年龄≥40 岁），这些患者的临床 T1-T2 和 N0 疾病，并且接受了 SLND（伴或不伴随后的 ALND）或 ALND。通过多变量逻辑回归评估种族、民族、保险类型、医疗机构和居住特征方面的利用差异。
共纳入 271689 例患者，其中 26527 例（10%）接受了 ALND，245162 例（90%）接受了 SLND。在调整了人口统计学和癌症特征后，黑人（比值比[OR]，1.11；95%置信区间[95%CI]，1.06-1.17）和西班牙裔女性（OR，1.16；95%CI，1.10-1.24）更有可能接受 ALND。与私人医疗保险相比，没有医疗保险的患者（OR，1.33；95%CI，1.19-1.47），以及在社区癌症中心接受治疗的患者（OR，1.60；95%CI，1.53-1.67），与学术/研究中心相比，更有可能接受 ALND。
尽管绝大多数女性接受 SLND，但早期乳腺癌 SLND 的应用存在显著差异，传统上服务不足的患者接受了不必要的广泛腋窝手术。需要加强患者和外科医生的教育，以减少影响患者生活质量的护理差异。
