Factors affecting use of SLNB
Four years ago, the ACS issued treatment guidelines in which sentinel lymph node biopsy (SLNB) was deemed an appropriate alternative to axillary lymph node dissection (ALND) for assessing lymph node status in breast cancer.
While clinical factors influence whether a woman undergoes SLNB or ALND, Amy Chen, MD, and colleagues found that nonclinical issues can also shape that decision (J Natl Cancer Inst 100:462-474, 2008).
“Better outcomes have been reported for patients receiving SLNB than for patients receiving ALND, including decreased edema, pain, hypoesthesia, and paresthesia,” wrote the authors from Emory University, the American College of Surgeons, The University of Texas Southwestern Medical School, and the ACS, which supported the study.
Dr. Chen’s group looked at the records of 490,899 women in the National Cancer Database to assess factors (see Table 2) that could predict the use of SLNB. Included in the analysis were SLNB and ALND procedures performed between 1998 and 2005.
A little over half (52.8%) of the 490,899 women had SLND while 47% underwent ALND. From 1998 to 2005, the use of SLNB jumped from 26.8% to 65.5%. In fact, the authors found that the year of diagnosis was the one variable associated with the greatest odds of SLNB being used.
However, women of color, older women, women with a lower income, and those on Medicare were less likely to receive SLNB. Also, women treated at community hospitals or community cancer centers had a lower likelihood of undergoing SLNB.
Patients with stage T2 disease were less likely to have SLNB than those with stage T1 disease. In addition, patients undergoing mastectomy were less likely to have SLNB than women undergoing breast-conserving surgery, although there are technical reasons for that, as lymph nodes are completely removed during mastectomy, Dr. Chen told ONI.
In another interesting finding, the authors recorded a steady upswing in the proportion of patients who had SLNB, regardless of the type of facility, until 2002 when that increase slowed down. Dr. Chen attributed this to the rapid integration of SLNB into routine clinical practice.
Whether economics played a role in women not undergoing SLNB could not be determined, Dr. Chen told ONI, based on the National Cancer Database. However, according to the American Medical Association, the reimbursement rate for ALND at $300.51 is slightly higher than that of SLNB at $202.24.
Dr. Chen called for more patient education on the pros and cons of SLNB. Referring physicians must also make it a point to send patients to facilities where SLNB is regularly performed, she said.