Dr Coopey on the Benefits of Axillary Surgery Omission or De-Escalation in Breast Cancer

Suzanne B. Coopey, MD, FACS, surgical oncologist, director, Wexford Breast Program, co-strategy and growth officer, Allegheny Health Network (AHN) Breast Cancer Program, AHN Cancer Institute, discusses the benefits seen with the de-escalation of axillary lymph node surgery for patients with breast cancer, as well as current recommendations for the de-escalation or omission of this procedure.

Axillary surgery is primarily performed to remove breast cancer that has already spread to nearby lymph nodes and prevent further metastasis. However, this procedure is associated with several complications, including arm lymphedema, chronic pain, chronic fluid collections, problems with range of motion in the shoulder, and axillary web syndrome, Coopey states. De-escalation of axillary surgery could reduce the likelihood of a patient with breast cancer developing these postoperative symptoms, Coopey says.

Axillary surgery consists of either sentinel lymph node biopsy (SNLD) alone, SNLB followed by axillary lymph node dissection (ALND), or ALND alone. There are several patient populations in which complete omission of axillary surgery, or de-escalation from ALND to SLNB alone should be considered, Coopey continues. According to the Choosing Wisely campaign, SLNB should not be routinely performed in women aged 70 or older who have early-stage endocrine receptor (ER)–positive, HER2-negative breast cancer, she says.

Additionally, ALND should be omitted in patients with 1 or 2 sentinel lymph nodes containing metastatic breast cancer provided they meet remaining criteria from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial (NCT00003855), Coopey details. These include histologically confirmed T1 or T2 invasive primary breast cancer, and no palpable axillary adenopathy. If patients convert from node-positive to node-negative status following the administration of neoadjuvant chemotherapy, ALND omission should also be discussed, Coopey notes.