Thomas Madeline B, Ghaffar Sumaya Abdul, Kadri Haaris, Quinn Christopher M, Leonard Laura D, Mott Nicole M, Franco Salvador Rodriguez, Assumpção Lia R, Ahrendt Gretchen, Tevis Sarah E A, Christian Nicole, Widner Jodi, Heelan Alicia A, Gleisner Ana L
Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, 12631 East 17th Ave, Aurora, CO, 80045, USA.
Department of Surgery, SSM Health / St. Louis University, St. Louis, MO, USA.
Breast Cancer Res Treat. 2025 Jul 22. doi: 10.1007/s10549-025-07789-1.
In 2016, the Society of Surgical Oncology and Choosing Wisely Campaign recommended against sentinel lymph node biopsy (SLNB) in women > 70 years with early-stage, hormone receptor-positive (ER/PR +) breast cancer, citing limited clinical benefit. Despite earlier evidence supporting de-implementation, SLNB rates remained high. We aimed to evaluate patient, tumor, facility, and unmeasured contextual factors associated with SLNB de-implementation using a national cohort.
We queried the National Cancer Database (NCDB) for women > 70 years diagnosed with early-stage ER/PR + and HER2-negative breast cancer between 2012 and 2019. A mixed effects logistic regression model assessed associations between SLNB non-utilization and patient, tumor, and facility-level characteristics. Interaction terms between year and facility breast surgery volume quartiles were included to examine trends over time. Reference Effect Measures (REM) were used to estimate the contribution of unmeasured contextual effects relative to measured covariates.
Among eligible patients, SLNB use declined from 86.7% in 2012 to 81.0% in 2019. SLNB use was significantly associated with age, insurance, urbanization, distance to facility, education, income, tumor size, lymphovascular invasion, treatment type, facility region, program type, and surgical volume. Academic programs had the highest adjusted odds of SLNB non-utilization (AOR 1.62; 95%CI: 1.29-2.02), while facilities in the South had the lowest (AOR 0.53; 95%CI: 0.45-0.63). High-volume centers de-implemented more rapidly post-2016, with 24% higher odds of SLNB non-utilization per year. REM analysis identified patient age and unmeasured contextual effects as the predominant drivers of de-implementation.
SLNB use in older women is influenced by multi-level factors, with patient age and unmeasured contextual effects driving de-implementation-though progress remain slow and limited in the United States.
2016年，外科肿瘤学会和明智选择运动建议，对于年龄超过70岁的早期激素受体阳性（ER/PR+）乳腺癌女性，不进行前哨淋巴结活检（SLNB），理由是临床获益有限。尽管早期有证据支持不再采用该检查，但SLNB的使用率仍然很高。我们旨在使用全国队列评估与SLNB不再采用相关的患者、肿瘤、机构及无法测量的背景因素。
我们查询了国家癌症数据库（NCDB）中2012年至2019年间年龄超过70岁、被诊断为早期ER/PR+且HER2阴性乳腺癌的女性患者。一个混合效应逻辑回归模型评估了未采用SLNB与患者、肿瘤及机构层面特征之间的关联。纳入年份与机构乳腺手术量四分位数之间的交互项，以研究随时间的趋势。使用参考效应量（REM）来估计相对于已测量协变量的未测量背景效应的贡献。
在符合条件的患者中，SLNB的使用率从2012年的86.7%下降至2019年的81.0%。SLNB的使用与年龄、保险、城市化程度、到机构的距离、教育程度、收入、肿瘤大小、淋巴管浸润、治疗类型、机构所在地区、项目类型及手术量显著相关。学术项目未采用SLNB的调整后优势比最高（AOR 1.62；95%CI：1.29 - 2.02），而南部地区的机构最低（AOR 0.53；95%CI：0.45 - 0.63）。2016年后，高手术量中心更快地不再采用SLNB，每年未采用SLNB的优势比高24%。REM分析确定患者年龄和未测量的背景效应是不再采用该检查的主要驱动因素。
老年女性中SLNB的使用受多层面因素影响，患者年龄和未测量的背景效应推动了不再采用该检查——尽管在美国进展仍然缓慢且有限。
