ASBRS Great Debate: Sentinel Node Biopsy in Patients Over 70 Years of Age
Controversy over the need for sentinel node biopsy (SNB) continues to exist for the optimal treatment of breast cancer in patients ≥ 70 years of age, especially in those with lower-risk disease. Clinicians must balance competing risks to give the best individualized care.
The American Society of Breast Surgeons (ASBrS) conducted a debate discussing the pros and cons of routinely performing SNB in this age group. Small, randomized studies have been conducted that show no overall survival benefit to axillary intervention (either axillary dissection or SNB) in patients with clinically T1N0 estrogen receptor (ER)- and progesterone receptor (PR)-positive, HER2/neu-negative tumors. There may be a small local recurrence benefit to axillary staging in patients who do not undergo radiation. Alternatively, axillary ultrasound, which carries a low false-negative rate for heavy disease burden, can be used to select patients who can avoid SNB.
Surgeons must continue to individualize care of breast cancer patients over 70 years of age in whom competing comorbidities may dictate care. No randomized clinical trials (RCTs) have found a survival benefit to axillary staging in this low-risk population. However, in healthy patients, axillary staging may improve local control, provide prognostic information, and help guide decisions regarding adjuvant therapy such as chemotherapy and radiation. Ongoing RCTs are evaluating the benefit of SNB in patients with a negative axillary ultrasound. Until those results are available, clinicians and patients must balance the risk and benefits to determine if SNB adds significant value to their overall care.
Lorraine Tafra would like to thank her team of breast surgeons for their wise counsel and generous sharing of their experiences and expertise.
- 1.Centers for Disease Control and Prevention. https://www.cdc.gov/cancer/breast/2018.
- 2.American Cancer Society. Breast Cancer Facts & Figures 2017–2018. Atlanta: American Cancer Society. 2017. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf.
- 3.Social Security Administration. Life Expectancy Calculator. https://www.ssa.gov/cgi-bin/longevity.cgi.
- 4.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.CrossRefPubMedGoogle Scholar
- 5.Boughey JC, Hoskin TL, Welsh JL, Day CN, Goetz MP, Haffty BG, et al. Using size and grade to identify women aged ≥ 70 years with endocrine-responsive breast cancer at low risk of nodal positivity: Letter to Editor Reply to “Sized influences nodal status in women aged ≥ 70 with endocrine responsive breast cancer” by Fitzal, Florian et al. in Ann Surg Oncol. Ann Surg Oncol. 2017;24(Suppl 3):557–558. https://doi.org/10.1245/s10434-017-6156-0.CrossRefPubMedGoogle Scholar
- 12.van de Water W, Markopoulos C, van de Velde CJ, Seynaeve C, Hasenburg A, Rea D, et al. Association between age at diagnosis and disease-specific mortality among postmenopausal women with hormone receptor-positive breast cancer. JAMA. 2012;307(6):590–597.Google Scholar
- 24.Lucci A, McCall LM, Beitsch PD, Whitworth PW, Reintgen DS, Blumencranz PW, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25(24):3657–3663.CrossRefPubMedGoogle Scholar
- 25.Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJ, Mansel RE, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15(12):1303–1310.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B, 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. J Clin Oncol. 2013;31(19):2382–2387.CrossRefPubMedPubMedCentralGoogle Scholar
- 36.van Roozendaal LM, Schipper RJ, Van de Vijver KK, Haekens CM, Lobbes MB, Tjan-Heijnen VC, et al. The impact of the pathological lymph node status on adjuvant systemic treatment recommendations in clinically node negative breast cancer patients. Breast Cancer Res Treat. 2014;143(3):469–476.CrossRefPubMedGoogle Scholar
- 39.Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–1241.CrossRefPubMedGoogle Scholar
- 40.Cyr AE, Tucker N, Ademuyiwa F, Margenthaler JA, Aft RL, Eberlein TJ, et al. Successful completion of the pilot phase of a randomized controlled trial comparing sentinel lymph node biopsy to no further axillary staging in patients with clinical T1–T2 N0 breast cancer and normal axillary ultrasound. J Am Coll Surg. 2016;223(2):399–407.CrossRefPubMedPubMedCentralGoogle Scholar