1.4 Axillary Node Dissection

In women with early stage breast cancer, an axillary lymph node dissection (ALND) to determine whether the axillary (arm pit) nodes are involved is commonly done for staging. If the nodes are positive, treatment is more aggressive. However, an alternatve to this type of staging is to use a genetic test panel like OncoTypeDx® to quantify the prognosis. A woman whose two oncologists and tumor board all said an ALND was essential for staging consulted one of us after obtaining an OncoTypeDx recurrence score of 7, indicating a low-risk tumor. An excerpt of the report from her test is pasted below:

Five-year recurrence or mortality risk for OncoTypeDx score =7 (95% CI) by treatment and nodal involvement. (Numbers come from post-hoc stratification of subjects in randomized trials comparing tamoxifen alone to tamoxifen plus chemo.)

Number of nodes involved (based on ALND)
Treatment No nodes + 1-3 Nodes+ ≥ 4 Nodes +
Tamoxifen 6% (3%-8%) 8% (4%-15%) 19% (11%-33%)
Tamoxifen + Chemotherapy 11% (7%-17%) 25% (16%-37%)

Do you agree with her treating clinicians that the ALND is essential for staging? What would be some reasons to do it or not do it?

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The most compelling reason to do the ALND would be if it provided information needed to guide subsequent management, i.e., if it sorted patients into groups in whom the benefits of chemotherapy did and did not exceed the risks and costs. However it appears that the OncoTypeDX test has already done this, and suggests that with a score of 7, tamoxifen alone is the best treatment choice regardless of nodal involvement.Another reason to do the ALND would be to provide prognostic information that might help with life decisions. If the patient would make different life decisions based on a 19% 5-year risk of death/recurrence vs a 6% risk, then the ALND might make sense. However, we would also need to know the likelihood of different ALND results. For example, if (as an outside consultant has suggested) the recurrence score of 7 and no nodes palpable on examination suggests the probability of ≥ 4 involved nodes is close to zero, the small chance of significantly changing the presumed prognosis would probably not be worth the pain and disability of the ALND.

The final reason for the patient to go ahead with the ALND would be to be a “good patient” and avoid conflict with her physicians. This patient instead preferred to attempt to educate her physicians about evidence-based medicine, but to date she has faced an uphill struggle in this endeavor.

As she put it, “My axillary nodes are happy where they are. I’m happy to forgo the additional information the doctors might get by taking them out and examining them.” Her decision is supported by long term follow-up of a randomized trial of axillary dissection in women known to have 1 or 2 positive nodes, which found no difference in mortality or recurrence risk after 10 years, with trends toward better outcome with no dissection. (Giuliano, Ballman et al. 2017)

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