The prognostic significance of further axillary dissection for sentinel lymph node micrometastases in female breast cancer: A competing risk analysis using the SEER database
Abstract:BackgroundSentinel lymph node (SLN) biopsy has been widely recognized as an excellent surgical and staging procedure for early-stage breast cancer, and its development has greatly improved the detection of micrometastases. However, the axillary treatment of micrometastasis has been the subject of much debate.MethodsWe identified 427,131 women diagnosed with breast cancer from 2010 to 2018 in the Surveillance, Epidemiology, and End Results (SEER) database. Patients whose nodal status was micrometastases (pTxN1m… Show more
“…The NOS was used to assess the quality of evidence in non-RCT trials. Five studies received a rating of seven or more stars, indicating high quality ( 15 , 16 , 19 , 21 , 35 ).Seven studies received a rating of six stars ( 11 , 20 , 22 , 23 , 26 , 34 , 36 ), and six studies were assessed as having four to five stars (See Table 1 ). The GRADEpro GDT tool was used to classify the evidence of RCTs comparing ALND to SLNB alone for patients with clinical node-negative early-stage breast cancer and positive sentinel lymph nodes.…”
BackgroundThe omission of axillary lymph node dissection (ALND) or axillary radiation (AxRT) remains controversial in patients with clinical node-negative early breast cancer and a positive sentinel lymph node.MethodsWe conducted a comprehensive review by searching PubMed, Embase, Web of Science, and Cochrane databases (up to November 2023). Our primary outcomes were overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and axillary recurrence (AR).ResultsWe included 26 studies encompassing 145,548 women with clinical node-negative early breast cancer and positive sentinel lymph node. Pooled data revealed no significant differences between ALND and sentinel lymph node biopsy (SLNB) alone in terms of OS (hazard ratio [HR]0.99, 95% confidence interval [CI] 0.91-1.08, p=0.84), DFS (HR 1.04, 95% CI 0.90-1.19, p=0.61), LRR (HR 0.76, 95% CI 0.45-1.20, p=0.31), and AR (HR 1.01, 95% CI 0.99-1.03, p=0.35). Similarly, no significant differences were observed between AxRT and SLNB alone for OS (HR 0.57, 95% CI 0.32-1.02, p=0.06) and DFS (HR 0.52, 95% CI 0.26-1.05, p=0.07). When comparing AxRT and ALND, a trend towards higher OS was observed the AxRT group (HR 0.08, 95% CI 0.67-1.15), but the difference did not reach statistical significance (p=0.35, I2 = 0%). Additionally, no significant differences significance observed for DFS or AR (p=0.13 and p=0.73, respectively) between the AxRT and ALND groups.ConclusionOur findings suggest that survival and recurrence rates are not inferior in patients with clinical node-negative early breast cancer and a positive sentinel lymph node who receive SLNB alone compared to those undergoing ALND or AxRT.
“…The NOS was used to assess the quality of evidence in non-RCT trials. Five studies received a rating of seven or more stars, indicating high quality ( 15 , 16 , 19 , 21 , 35 ).Seven studies received a rating of six stars ( 11 , 20 , 22 , 23 , 26 , 34 , 36 ), and six studies were assessed as having four to five stars (See Table 1 ). The GRADEpro GDT tool was used to classify the evidence of RCTs comparing ALND to SLNB alone for patients with clinical node-negative early-stage breast cancer and positive sentinel lymph nodes.…”
BackgroundThe omission of axillary lymph node dissection (ALND) or axillary radiation (AxRT) remains controversial in patients with clinical node-negative early breast cancer and a positive sentinel lymph node.MethodsWe conducted a comprehensive review by searching PubMed, Embase, Web of Science, and Cochrane databases (up to November 2023). Our primary outcomes were overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and axillary recurrence (AR).ResultsWe included 26 studies encompassing 145,548 women with clinical node-negative early breast cancer and positive sentinel lymph node. Pooled data revealed no significant differences between ALND and sentinel lymph node biopsy (SLNB) alone in terms of OS (hazard ratio [HR]0.99, 95% confidence interval [CI] 0.91-1.08, p=0.84), DFS (HR 1.04, 95% CI 0.90-1.19, p=0.61), LRR (HR 0.76, 95% CI 0.45-1.20, p=0.31), and AR (HR 1.01, 95% CI 0.99-1.03, p=0.35). Similarly, no significant differences were observed between AxRT and SLNB alone for OS (HR 0.57, 95% CI 0.32-1.02, p=0.06) and DFS (HR 0.52, 95% CI 0.26-1.05, p=0.07). When comparing AxRT and ALND, a trend towards higher OS was observed the AxRT group (HR 0.08, 95% CI 0.67-1.15), but the difference did not reach statistical significance (p=0.35, I2 = 0%). Additionally, no significant differences significance observed for DFS or AR (p=0.13 and p=0.73, respectively) between the AxRT and ALND groups.ConclusionOur findings suggest that survival and recurrence rates are not inferior in patients with clinical node-negative early breast cancer and a positive sentinel lymph node who receive SLNB alone compared to those undergoing ALND or AxRT.
“…Then, 72 papers were retrieved for full-text review. Finally, 30 reports for 26 studies were included in the systematic research and meta-analysis according to the inclusion and exclusion criteria [ 12 , 13 , 30 – 57 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…Fourteen papers compared the OS between patients treated with ALND and SLNB only [ 13 , 31 , 34 , 37 , 39 , 40 , 42 , 44 , 48 , 50 , 51 , 53 , 55 , 57 ]. A fixed-effect statistical model (Q-test: p = 0.26 and I 2 = 16%) revealed that the OS was not significantly different between the SLNB only and ALND groups (HR = 0.97, 95% CI: 0.92–1.03, p = 0.37).…”
Section: Resultsmentioning
confidence: 99%
“…A fixed-effect statistical model (Q-test: p = 0.26 and I 2 = 16%) revealed that the OS was not significantly different between the SLNB only and ALND groups (HR = 0.97, 95% CI: 0.92–1.03, p = 0.37). Six papers compared the DFS between patients in the Micro/ITC treated ALND and SLNB only groups [ 13 , 31 , 39 , 40 , 55 , 57 ]. No statistical difference for the DFS was found between the two interventions (HR = 1.04, 95% CI: 0.91–1.19, p = 0.57) (Fig.…”
Background
This systematic review and meta-analysis aimed to study the evidence on the efficacy and safety of omitting axillary lymph node dissection (ALND) for patients with clinically node-negative but sentinel lymph node (SLN)-positive breast cancer using all the available evidence.
Methods
The Embase, Medline, and Cochrane Library databases were searched through February 25, 2023. Original trials that compared only the sentinel lymph node biopsy (SLNB) with ALND as the control group for patients with clinically node-negative but SLN-positive breast cancer were included. The primary outcomes were axillary recurrence rate, total recurrence rate, disease-free survival (DFS), and overall survival (OS). Meta-analyses were performed to compare the odds ratio (OR) in rates and the hazard ratios (HR) in time-to-event outcomes between both interventions. Based on different study designs, tools in the revised Cochrane risk of bias tool were used for randomized trials and the risk of bias in nonrandomized studies of interventions to assess the risk of bias for each included article. Funnel plots and Egger's test were used for the publication’s bias assessment.
Results
In total, 30 reports from 26 studies were included in the systematic review (9 reports of RCTs, 21 reports of retrospective cohort studies). According to our analysis, omitting ALND in patients with clinically node-negative but SLN-positive breast cancer had a similar axillary recurrence rate (OR = 0.95, 95% confidence interval (CI): 0.76–1.20), DFS (HR = 1.02, 95% CI: 0.89–1.16), and OS (HR = 0.97, 95% CI: 0.92–1.03), but caused a significantly lower incidence of adverse events and benefited in locoregional recurrence rate (OR = 0.76, 95% CI: 0.59–0.97) compared with ALND.
Conclusion
For patients with clinically node-negative but SLN-positive breast cancer (no matter the number of the positive SLN), this review showed that SLNB alone had a similar axillary recurrence rate, DFS, and OS, but caused a significantly lower incidence of adverse events and showed a benefit for the locoregional recurrence compared with ALND. An OS benefit was found in the Macro subset that used SLNB alone versus complete ALND. Therefore, omitting ALND is feasible in this setting.
Trial registration
CRD 42023397963
“…As previously reported, the sub‐hazard ratio (SHR) was determined to be similar to the hazard ratio, but taking into consideration the hazard of competing events, which was suitable for exploring CVD‐related mortality among cancer patients. 16 , 17 In our study, competing risk regression was used to evaluate the association between age at diagnosis and CVD‐related mortality among major gastrointestinal cancers. Patients who died from cancer were regarded as competing events.…”
BackgroundStudies have reported age as a risk factor for cardiovascular disease (CVD)‐related mortality; however, only a few studies have focused on the relationship between age and CVD‐related mortality, especially among major gastrointestinal cancers.MethodThe present retrospective cohort enrolled patients with colorectal, pancreatic, hepatocellular, gastric, and esophageal cancer between 2000 to 2015 from the Surveillance, Epidemiology and End Results Registry (SEER). Standardized mortality ratio (SMR), competing risk regression, and restricted cubic spline (RCS) analyses were used in our study.ResultsWe analyzed 576,713 patients with major gastrointestinal cancers (327,800 patients with colorectal cancer, 93,310 with pancreatic cancer, 69,757 with hepatocellular cancer, 52,024 with gastric cancer, and 33,822 with esophageal cancer). Overall, CVD‐related mortality gradually decreased every year, and the majority were older patients. All cancer patients had a higher CVD‐related mortality rate than the general U.S. population. The adjusted sub‐hazard ratios for middle‐aged with colorectal cancer, pancreatic cancer, hepatocellular cancer, gastric cancer, and esophageal cancer were 2.55 (95% CI: 2.15–3.03), 1.77 (95% CI: 1.06–2.97), 2.64 (95% CI: 1.60–4.36), 2.15 (95% CI: 1.32–3.51), and 2.28 (95% CI: 1.17–4.44), respectively. The adjusted sub‐hazard ratios for older patients with colorectal cancer, pancreatic cancer, hepatocellular cancer, gastric cancer, and esophageal cancer were 11.23 (95% CI: 9.50–13.27), 4.05 (95% CI: 2.46–6.66), 4.47 (95% CI: 2.72–7.35), 7.16 (95% CI: 4.49–11.41), and 4.40 (95% CI: 2.28–8.48), respectively. A non‐linear relationship between age at diagnosis and CVD‐related mortality was found in colorectal cancer, pancreatic cancer, and esophageal cancer; their reference ages were 67, 69, and 66 years old, respectively.ConclusionThis study demonstrated that age was a risk factor for CVD‐related mortality among major gastrointestinal cancers.
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