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Use of sentinel-lymph-node biopsies rising in patients with inflammatory breast cancer, against guidelines

JAMA Network Open
Reuters Health - 15/02/2022 - Sentinel-lymph-node biopsies are frequently and increasingly being used in patients with inflammatory breast cancer, contrary to guidelines which recommend axillary-lymph-node dissection for these women, a new study shows.

An analysis of data from more than 1,000 adult patients diagnosed with nonmetastatic inflammatory breast cancer between 2012 and 2017 reveals that the proportion of patients receiving sentinel-lymph-node biopsies (SLNBs) rose from 11% to 22% (P=0.001), researchers report in JAMA Network Open.

"Patients with inflammatory breast cancer are being increasingly commonly treated with a less aggressive surgical approach, where only the sentinel lymph nodes are biopsied, rather than the standard of care, guideline-recommended, full axillary lymph-node dissection, despite multiple studies showing that sentinel-lymph-node biopsy may be an ineffective technique in patients with inflammatory breast cancer," said coauthor Dr. Kevin T. Nead of the University of Texas MD Anderson Cancer Center in Houston.

"Patients with inflammatory breast cancer have significantly worse outcomes than patients with other forms of locally advanced breast cancer," Dr. Nead told Reuters Health by email. "They deserve their best chance of cure and, based on the existing data, that includes an axillary-lymph-node dissection rather than a sentinel-lymph-node biopsy. That being said, there is significant room to improve outcomes for patients with inflammatory breast cancer by optimizing and personalizing treatment approaches through prospective clinical trials."

To take a closer look at trends in the use of SLNB in patients with inflammatory breast cancer, Dr. Nead and his colleagues conducted a cohort study using data from the National Cancer Database (NCDB), a nationwide hospital-based cancer registry representing approximately 70% of all new cancers diagnosed in the U.S.

Between 2012 and 2017, 1,096 of more than 1.4 million women with breast cancer had nonmetastatic inflammatory disease. Among those patients (median age, 56), 8% were Hispanic women, 14% were non-Hispanic Black women and 74% non-Hispanic white women.

Out of the 1,096, 186 (17%) received any SLNB, with 119 (64%) of that group not undergoing a completion axillary-lymph-node dissection (ALND). Compared with the women who received ALND, those who underwent any SLNB had a later date of diagnosis, earlier clinical nodal stage (25% vs. 14% at clinical node stage 0) and were more likely to undergo partial mastectomy (5% vs. 1.2%).

The study did not address why some women received SLNB, Dr. Nead said.

"Our study did not examine this, but the reasons, among others, likely include a multifactorial combination of well-intentioned de-escalation of care in patients with more favorable disease and inadvertent de-escalation of care given that inflammatory breast cancer is relatively uncommon and has unique guidelines that differ from the more traditional forms of non-inflammatory breast cancer," he added.

The study spotlights the fact that some surgeons are not following guidelines, said Dr. Stephanie Bernik, an associate professor of surgery at the Icahn School of Medicine at Mount Sinai and chief of the breast service at Mount Sinai West in New York City.

"It is important to remember that when performing a surgical procedure, a surgeon should most often try to follow guidelines determined by clinical studies," Dr. Bernik, who was not involved in the research, told Reuters Health by email. "Exceptions do occur, often based on circumstances for an individual patient. In this study, however, the shift to use of a sentinel node biopsy in those with inflammatory cancer seems more than circumstantial."

"It appears that surgeons are assuming that using a sentinel-node biopsy in this setting is acceptable, which has not been studied in any large randomized trials," she added. "In fact, the present data suggests that the sentinel node is not accurate in this group of patients. One cannot make these assumptions and we must try to adhere to guidelines in order to deliver optimal care."

With big improvements in chemotherapy, it's possible that some surgeons are assuming that care of these patients can change, said Dr. Lisa Jacobs, an associate professor of surgery and division chief for breast surgery at Johns Hopkins Medicine, who also was not involved in the study.

"Some physicians may be asking if we need to be as aggressive surgically now that we have really good chemotherapy," she said. "They may be trying a de-escalation of therapies. But we need to study this to make sure that it's safe."

"We really need to look hard at things like the survival component," Dr. Jacobs said. "This study did not look at survival."

SOURCE: https://bit.ly/3rOHGhv JAMA Network Open, online February 11, 2022.

By Linda Carroll

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