Abstract
Background: Because of the general acceptance of the NSABP B-04 study, prophylactic axillary node dissection for women with clinically negative axillae is considered diagnostic, but not therapeutic, by many oncologists. Nevertheless, several authors have shown that B-04 did not include enough patients to exclude a small survival advantage.
Methods: A Bayesian meta-analysis of the available literature was performed comparing standard treatment to standard treatment without axillary node dissection. Six randomized controlled trials were identified, consisting of nearly 3000 patients and spanning four decades.
Results: All six trials showed that prophylactic axillary node dissection improved survival, ranging from 4% to 16%, corresponding to a risk reduction of 7%-46%. Combining the six trials showed an average survival benefit of 5.4% (95% CI = 2.7-8.0%, probability of survival benefit. > 99.5%). Adjusting for biases in the individual studies did not alter the conclusions, nor did subset analysis of Stage I patients.
Conclusions: Axillary node dissection improves survival in women with operable breast cancer. Nevertheless, two important limitations of this analysis are noteworthy. Few of the patients in the six trials had T1a tumors, so extrapolation of these results to this subset (and those with nonpalpable tumors) may be inappropriate. Essentially no patients in the six trials were treated with adjuvant therapy, as contrasted to current clinical practice. It is possible that the risk reduction seen in this meta-analysis may be diminished in patients receiving adjuvant chemotherapy. Despite these limitations, this study suggests that axillary dissection should be performed in most women with palpable tumors for diagnostic, as well as therapeutic, purposes.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
REFERENCES
NIH consensus conference. Treatment of early-stage breast cancer. JAMA 1991;265:391–4.
Ruffin WK, Stacey-Clear A, Younger J, Hoover HC Jr. Rationale for routine axillary dissection in carcinoma of the breast. J Am Coll Surg 1995;180:245–51.
Balch CM, Singletary SE, Bland KI. Clinical decision-making in early breast cancer. Ann Surg 1993;217:207–25.
Eberlein TJ Current management of carcinoma of the breast. Ann Surg 1994;220:121–36.
Fisher B, Wolmark N, Bauer M, Redmond C, Gebhardt M. The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histologic nodal status in carcinoma of the breast. Surg Gynecol Obstet 1981;152:765–72.
Dees EC, Shulman LN, Souba WW, Smith BL. Does information from axillary dissection change treatment in clinically node-negative patients with breast cancer? An algorithm for assessment of impact of axillary dissection. Ann Surg 1997;226:279–86.
Hayward J, Caleffi M. The significance of local control in the primary treatment of breast cancer. Arch Surg 1987;122:1244–7.
Cady B, Stone MD, Wayne J. New therapeutic possibilities in primary invasive breast cancer. Ann Surg 1993;218:338–49.
Deckers PJ. Axillary dissection in breast cancer: when, why, how much, and for how long? Another operation soon to be extinct? J Surg Oncol 1991;48:217–9.
Haffty BC, McKhann C, Beinfield M, Fischer D, Fischer JJ. Breast conservation therapy without axillary dissection: A rational treatment strategy in selected patients. Arch Surg 1993;12:1315–9.
Silverstein MJ, Gierson ED, Waisman JR, Senofsky GM, Colburn WJ, Gamagami P. Axillary lymph node dissection for T1a breast carcinoma: Is it indicated? Cancer 1994;73:664–7.
Hoe AL, Iven D, Royle GT, Taylor I. Incidence of arm swelling following axillary clearance for breast cancer. Br J Surg 1992;79:261–2.
Aitken RJ, Gaze MN, Rodger A, Chetty U, Forrest APM. Arm morbidity within a trial of mastectomy and either nodal sample with selective radiotherapy or axillary clearance. Br J Surg 1989;76:568–71.
Ivens D, Hoe AL, Podd TJ, Hamilton CR, Taylor I, Royle GT. Assessment of morbidity from complete axillary dissection. Br J Cancer 1992;66:136–8.
Hladiuk M, Huchcroft S, Temple W, Schnurr BE. Arm function after axillary dissection for breast cancer: a pilot study to provide parameter estimates. J Surg Oncol 1992;50:47–52.
Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med 1992;93:543–8.
Clarke D, Martinez A, Cox RS, Goffinet DR. Breast edema following staging axillary node dissection in patients with breast carcinoma treated by radical radiotherapy. Cancer 1982;49:2295–9.
Lin PP, Allison DC, Wainstock J, et al. Impact of axillary lymph node dissection on the therapy of breast cancer patients. J Clin Oncol 1993;11:1536–44.
Fisher B, Redmond C, Fisher ER, et al. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 1985;312:674–81.
Gardner B, Feldman J. Are positive axillary nodes in breast cancer markers for incurable disease? Ann Surg 1993;218:270–8.
Harris JR, Osteen RT. Patients with early breast cancer benefit from effective axillary treatment. Breast Cancer Res Treat 1985;5:17–21.
Recht A, Houlihan MJ. Axillary lymph nodes in breast cancer—a review. Cancer 1995;76:1491–1512.
Early Breast Cancer Trialists’ Collaborative Group. Effects of radiotherapy and surgery in early breast cancer—An overview of the randomized trials. N Engl J Med 1995;333:1444–55.
Cuzick J, Stewart H, Peto R, et al. Overview of randomized trials of postoperative adjuvant radiotherapy in breast cancer. Cancer Treat Rep 1987;71:15–29.
Cuzick J, Stewart H, Peto R, et al. Overview of randomized trials comparing radical mastectomy without radiotherapy against simple mastectomy with radiotherapy in breast cancer. Cancer Treat Rep 1987;71:7–14.
Brinkley D, Haybittle JL. Treatment of Stage-II carcinoma of the female breast. Lancet 1966;2:291–5.
Early Breast Cancer Trialists’ Collaborative Group. Treatment of early breast cancer. Vol. 1. Worldwide evidence 1985–1990. Oxford: Oxford University Press, 1990.
Johansen H, Kaae S, Schiodt T. Simple mastectomy with postoperative irradiation versus extended radical mastectomy in breast cancer: A twenty-five year follow-up of a randomized trial. Acta Oncol 1990;29:709–15.
Kaae S, Johansen H. Does simple mastectomy followed by irradiation offer survival comparable to radical procedures? Int J Radiation Oncol Biophys 1977;2:1163–6.
Bruce J. Operable cancer of the breast—A controlled clinical trial. Cancer 1971;28:1443–52.
Hamilton T, Langlands AO, Prescott RJ. The treatment of operable cancer of the breast: a clinical trial in the South-East region of Scotland. Br J Surg 1974;61:758–61.
Langlands AO, Prescott RJ, Hamilton T. A clinical trial in the management of operable cancer of the breast. Br J Surg 1980;67:170–4.
Atkins H, Hayward JL, Klugman DJ, Wayte AB. Treatment of early breast cancer: A report after ten years of a clinical trial. Br Med J 1972;2:423–9.
Hayward JL. The Guy’s trial of treatments of “early” breast cancer. World J Surg 1977;1:314–6.
Hayward JI. The Guy’s Hospital trials on breast conservation. In: Harris JR, Hellman S, Silen W, eds. Conservative management of breast cancer: new surgical and radiotherapeutic techniques. Philadelphia: JB Lippincott, 1983:77–90.
Cabanes PA, Salmon RJ, Vilcoq JR, et al. Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer. Lancet 1992;339:1245–8.
Overgaard M, Christensen JJ, Johansen H. Evaluation of radiotherapy in high-risk breast cancer patients: Report from the Danish Breast Cancer Cooperative Group (DCBC 82) trial. Int J Radiation Oncol Biol Phys 1990;19:1121–4.
Turnbull AR, Chant ADB, Buchanan RB, Turner DTL, Shepherd JM, Fraser JD. Treatment of early breast cancer. Lancet 1978;2:7–9.
Lythgoe JP, Palmer MK. Manchester regional breast study—5 and 10 year results. Br J Surg 1982;69:693–6.
Houghton J, Baum M, Haybittle JL. Role of radiotherapy following total mastectomy in patients with early breast cancer. World J Surg 1994;18:117–22.
Helman P, Bennett MB, Louw JH, et al. Interim report on trial of treatment for operable breast cancer. S Afr Med J 1972;46:1374–5.
Dent DM, Gudgeon CA, Murray EM. Mastectomy with axillary clearance versus mastectomy without it. Late results of a trial in which patients had no adjuvant chemo-, radio- or endocrine therapy. S Afr Med J 1996;86:670–1.
Forrest APM, Everington D, McDonald CC, Steele RJC, Chetty U, Stewart HJ. The Edinburgh randomized trial of axillary sampling or clearance after mastectomy. Br J Surg 1995;82:1504–8.
Raudenbush SW. Random effects models. In: Cooper H, Hedges LV, eds. The Handbook of Research Synthesis. New York: Russell Sage Foundation, 1994:301–22.
Brophy JM, Joseph L. Placing trials in context using Bayesian analysis—GUSTO revisited by Reverend Bayes. JAMA 1995;273:871–5.
Lewis RJ, Wears RL. An introduction to the Bayesian analysis of clinical trials. Ann Emerg Med 1993;22:1328–36.
Eddy DM, Hasselblad V, Schachter R. An introduction to a Bayesian method for meta-analysis: the Confidence Profile method. Med Decis Making 1990;10:15–23.
Eddy DM, Hasselblad V, Schachter R. A Bayesian method for synthesizing evidence: The Confidence Profile method. Int J Technology Assessment Health Care 1990;6:31–55.
Eddy DM, Hasselblad V, Schachter R. Meta-analysis by the Confidence Profile Method. Boston: Academic Press, 1992.
L’Abbe KA, Detsky AS, O’Rourke K. Meta-analysis in clinical research. Ann Intern Med 1987;107:224–33.
Early Breast Cancer Trialists’ Collaborative Group. Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 1992;339:1–15, 71–85.
Rockette HE, Redmond CK. Limitations and advantages of metaanalysis in clinical trials. Rec Results Cancer Research 1988;111:99–104.
Levitt SH, Aeppli DM, Nierengarten ME. The impact of radiation on early breast carcinoma survival—A Bayesian analysis. Cancer 1996;78:1035–42.
Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985;312:665–73.
Cady B, Stone MD, Schuler JG, et al. The new era in breast cancer: invasion, size and nodal involvement dramatically decreasing as a result of mammographic screening. Arch Surg 1996;131:301–8.
Fisher B, Brown A, Mamounas, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol 1997;15:2483–93.
Mustafa IA, Bland KI. Indications for axillary dissection in T1 breast cancer. Ann Surg Oncol 1998;5:23–7.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Orr, R.K. The Impact of Prophylactic Axillary Node Dissection on Breast Cancer Survival—A Bayesian Meta-Analysis. Ann Surg Oncol 6, 109–116 (1999). https://doi.org/10.1007/s10434-999-0109-1
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/s10434-999-0109-1