Annals of Surgical Oncology

, Volume 25, Issue 10, pp 2890–2898 | Cite as

Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival

  • Nina Tamirisa
  • Samantha M. Thomas
  • Oluwadamilola M. Fayanju
  • Rachel A. Greenup
  • Laura H. Rosenberger
  • Terry Hyslop
  • E. Shelley Hwang
  • Jennifer K. PlichtaEmail author
Breast Oncology



Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery.


Patients aged ≥70 years in the National Cancer Database (2004–2014) with cT1-3, cN0 breast cancer were divided into two cohorts—those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson–Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS.


Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p < 0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p < 0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p < 0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61–1.70).


For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.



Portions of this manuscript were presented at the 2018 Annual Meeting of the American Society of Breast Surgeons (ASBrS). The NCDB is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospitals participating in the CoC NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.


Dr. O. Fayanju is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award number 5KL2TR001115 (PI: Boulware). Dr. R. Greenup is supported by NIH BIRCWH K12HD043446 (PI: Andrews). This work is also supported by the Duke Cancer Institute through NIH grant P30CA014236 (PI: Kastan). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.


Nina Tamirisa, Samantha M. Thomas, Oluwadamilola M. Fayanju, Rachel A. Greenup, Laura H. Rosenberger, Terry Hyslop, E. Shelley Hwang, and Jennifer K. Plichta have no disclosures to declare.

Supplementary material

10434_2018_6595_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 30 kb)
10434_2018_6595_MOESM2_ESM.tiff (4.2 mb)
Supplemental Figure 1 Patient flow diagram of inclusion and exclusion criteria (TIFF 4286 kb)
10434_2018_6595_MOESM3_ESM.tiff (12.6 mb)
Supplemental Figure 2 Kaplan-Meier curve for unadjusted overall survival of all patients (N=133778) (TIFF 12920 kb)
10434_2018_6595_MOESM4_ESM.tiff (12.6 mb)
Supplemental Figure 3 Kaplan-Meier curve for unadjusted overall survival of patients with cT1/cN0/cM0, grade 1/2, ER+ breast cancer by receipt of axillary lymph node surgery and pN stage (N=83797). ER: estrogen receptor. LN: lymph node (TIFF 12920 kb)


  1. 1.
    Martelli G, Miceli R, Daidone MG, et al. Axillary dissection versus no axillary dissection in elderly patients with breast cancer and no palpable axillary nodes: results after 15 years of follow-up. Ann Surg Oncol. 2011;18(1):125–133.CrossRefGoogle Scholar
  2. 2.
    Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. Journal of clinical oncology. 2013;31(19):2382–2387.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Goldberg JI, Riedel ER, Morrow M, Van Zee KJ. Morbidity of sentinel node biopsy: relationship between number of excised lymph nodes and patient perceptions of lymphedema. Ann Surg Oncol. 2011;18(10):2866–2872.CrossRefGoogle Scholar
  4. 4.
    McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol. 2008;26(32):5213–5219.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Biganzoli L, Wildiers H, Oakman C, et al. Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol. 2012;13(4):e148–160.CrossRefGoogle Scholar
  6. 6.
    Giordano SH, Hortobagyi GN, Kau SW, Theriault RL, Bondy ML. Breast cancer treatment guidelines in older women. J Clin Oncol. 2005;23(4):783–791.CrossRefGoogle Scholar
  7. 7.
    Owusu C, Lash TL, Silliman RA. Effect of undertreatment on the disparity in age-related breast cancer-specific survival among older women. Breast Cancer Res Treat. 2007;102(2):227–236.CrossRefGoogle Scholar
  8. 8.
    Muss HB, Woolf S, Berry D, et al. Adjuvant chemotherapy in older and younger women with lymph node-positive breast cancer. JAMA. 2005;293(9):1073–1081.CrossRefGoogle Scholar
  9. 9.
    Welsh JL, Hoskin TL, Day CN, Habermann EB, Goetz MP, Boughey JC. Predicting Nodal Positivity in Women 70 Years of Age and Older with Hormone Receptor-Positive Breast Cancer to Aid Incorporation of a Society of Surgical Oncology Choosing Wisely Guideline into Clinical Practice. Ann Surg Oncol. 2017;24(10):2881–2888.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Chagpar AB, Hatzis C, Pusztai L, et al. Association of LN Evaluation with Survival in Women Aged 70 Years or Older With Clinically Node-Negative Hormone Receptor Positive Breast Cancer. Ann Surg Oncol. 2017;24(10):3073–3081.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    American College of Surgeons: National Cancer Data Base [cited 19 Jun 2015]. Accessed 1 Aug 2016.
  12. 12.
    Mandrekar JN, Mandrekar SJ. An Introduction to Matching and its Application using SAS. Paper 208–209, SESUG 29. Available at: Accessed 23 Apr 2018.
  13. 13.
    Breslow NE DN. Statistics Methods in Cancer Research: Volume I – The Analysis of Case-Control Studies. Lyon: International Agency for Research on Cancer; 1980.Google Scholar
  14. 14.
  15. 15.
    Chagpar AB, McMasters KM, Edwards MJ, Trial NAFTA. Can sentinel node biopsy be avoided in some elderly breast cancer patients? Ann Surg. 2009;249(3):455–460.CrossRefGoogle Scholar
  16. 16.
    Caywood J, Gray RJ, Hentz J, Pockaj BA. Older age independently predicts a lower risk of sentinel lymph node metastasis in breast cancer. Ann Surg Oncol. 2005;12(12):1061–1065.CrossRefGoogle Scholar
  17. 17.
    Gentilini O, Veronesi U. Abandoning sentinel lymph node biopsy in early breast cancer? A new trial in progress at the European Institute of Oncology of Milan (SOUND: Sentinel node vs Observation after axillary UltraSouND). Breast. 2012;21(5):678–681.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Mendenhall NP. Age-related variations in the use of axillary dissection. Int J Radiat Oncol Biol Phys. 2002;54(3):637–639.CrossRefGoogle Scholar
  19. 19.
    Wildiers H, Van Calster B, van de Poll-Franse LV, et al. Relationship between age and axillary lymph node involvement in women with breast cancer. J Clin Oncol. 2009;27(18):2931–2937.CrossRefGoogle Scholar
  20. 20.
    Sun SX, Hollenbeak CS, Leung AM. Deviation from the Standard of Care for Early Breast Cancer in the Elderly: What are the Consequences? Ann Surg Oncol. 2015;22(8):2492–2499.CrossRefGoogle Scholar
  21. 21.
    Okonji DO, Sinha R, Phillips I, Fatz D, Ring A. Comprehensive geriatric assessment in 326 older women with early breast cancer. British Journal of Cancer. 2017;117(7):925–931.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Nina Tamirisa
    • 1
  • Samantha M. Thomas
    • 2
    • 3
  • Oluwadamilola M. Fayanju
    • 1
    • 2
  • Rachel A. Greenup
    • 1
    • 2
  • Laura H. Rosenberger
    • 1
    • 2
  • Terry Hyslop
    • 2
    • 3
  • E. Shelley Hwang
    • 1
    • 2
  • Jennifer K. Plichta
    • 1
    • 2
    Email author
  1. 1.Department of SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Duke Cancer Institute, Duke University Medical CenterDurhamUSA
  3. 3.Department of Biostatistics and BioinformaticsDuke UniversityDurhamUSA

Personalised recommendations