Fox Chase Cancer Center Researchers Find That Removal of Lymph Nodes Can be Avoided for Most Older Patients Undergoing Mastectomy for Ductal Carcinoma In Situ

Austin D. Williams, MD, MSEd, Assistant Professor in the Division of Breast Surgery, was the lead author on a study that found that removal of lymph nodes can be avoided for most older patients undergoing mastectomy for ductal carcinoma.

PHILADELPHIA (September 24, 2024) - Most patients 70 or older who are undergoing mastectomy for estrogen receptor-positive ductal carcinoma in situ (DCIS) can avoid removal of their lymph nodes, according to a recently published study from researchers at Fox Chase Cancer Center.

Estrogen receptor-positive DCIS is a noninvasive breast cancer that requires estrogen to grow. Axillary surgery, a procedure often done in patients with breast cancer in conjunction with a mastectomy or lumpectomy, involves removing lymph nodes to check for signs that cancer has spread.

"We always want to avoid procedures that aren't necessary, and we have been successful in doing so for many older patients with invasive cancer, so we hope this study prompts surgeons to do the same for those undergoing mastectomy for DCIS," said Austin D. Williams, MD, MSEd, lead author on the study and an Assistant Professor in the Division of Breast Surgery within the Department of Surgery at Fox Chase.

"Our data, and the use of adjunctive tools like axillary ultrasound, might help surgeons in counseling patients for or against doing the lymph node part the surgery," added Williams, who conducted the study with other Fox Chase colleagues, including first author Elissa Dalton, MD, who was a Breast Surgical Oncology Fellow when the study was conducted.

The researchers found that the number of patients who undergo lymph node surgery has increased over time, with surgeons omitting it in only 14% of patients. They sought to determine how frequently lymph nodes tested positive for the presence of cancer after axillary surgery in women 70 or older to determine the impact of the surgery on treatment decisions. Females 70 or older with DCIS undergoing mastectomy were identified from the National Cancer Database.

To evaluate the 9,030 patients who underwent axillary surgery, researchers used recommended guidelines from Choosing Wisely, an initiative by the American Board of Internal Medicine that facilitates discussions about avoiding unnecessary medical tests, treatments, and procedures. Using those criteria, researchers concluded that 93% of the entire cohort and 97% of estrogen receptor-positive DCIS patients could have avoided axillary surgery.

"Of those who were ultimately found to have invasive cancer, 87% had no lymph nodes that tested positive for cancer," said Williams. "These findings offer important insights because surgical procedures can impact other treatments for these patients later on, but we found that the recommendation for chemotherapy was rare even among patients with positive nodes."

Researchers concluded that axillary surgery can routinely be omitted for most patients 70 and older who are undergoing mastectomy for estrogen receptor-positive DCIS. These findings align with recommendations for invasive cancer, and omission of axillary surgery can also be considered in those patients with estrogen receptor-negative DCIS.

The study, "Nodal Surgery For Patients ≥ 70 Undergoing Mastectomy For DCIS? Choose Wisely," was published in Annals of Surgical Oncology.