Patterns of axillary surgical care for breast cancer in the era of sentinel lymph node biopsy.

Background: Population-based overall patterns of surgical management of the axilla in women with operable breast cancer during the era of adoption of sentinel lymph node biopsy (SLNB) were studied.

Methods: Women with operable breast carcinoma residing in 14 geographic areas of the Surveillance, Epidemiology, and End Results (SEER) cancer registries (1998-2004, n=239,661) were assessed for axillary surgical patterns of care.

Results: Use of SLNB increased from 11 to 59%. Use of no axillary surgery decreased from 14 to 6.6%. In pathologic node-negative women, use of axillary lymph node dissection (ALND) decreased from 94 to 36%. Independent factors most associated with failure to receive SLNB included diagnosis year (2000: 62%; 2004: 29%), surgery (mastectomy: 64%; breast-conserving surgery: 36%), tumor size (T3: 71%; T2: 56%; T1: 40%), age (>or= 70 years: 50%; <70 years: 45%), grade (high: 42%; low: 38%), urbanity (non-large metropolitan area: 49%; large metropolitan area: 42%), and, by quartile, poverty (highest: 47%; lowest: 35%), and white-collar employment (lowest: 56%; highest: 47%). In pathologic node-positive women who had SLNB, failure to undergo completion ALND increased from 20% in 1998 to 32% in 2004. Patients with smaller, lower-grade tumors, and those with smaller size of nodal metastasis, lack of extracapsular extension, age >or= 70 years, increased linguistic isolation, African-American or Hispanic race/ethnicity, and white-collar employment were less likely to undergo completion ALND.

Conclusions: Management of the axilla changed dramatically during the period of rapid adoption of SLNB. Patterns of care suggest both appropriate and inappropriate selection for SLNB and ALND.