Is axillary lymph node dissection indicated for early-stage breast cancer?A decision analysis

Purpose: Axillary lymph node dissection (ALND) has been a standard procedur e in the management of breast cancer. In a patient with a clinically negati ve axilla, ALND is performed primarily for staging purposes, to guide adjuv ant treatment. Recently, the routine use of ALND has been questioned becaus e the results of the procedure may not change the choice of adjuvant system ic therapy and/or the survival benefit of a change in adjuvant therapy woul d be small. We constructed a decision model to quantify the benefits of ALN D for patients eligible for breast-conserving therapy. Methods: Patients were grouped by age, tumor size, and estrogen receptor (E R) status. The model uses the Oxford overviews and three combined Cancer an d Leukemia Group B studies. We assumed that patients who did not undergo AL ND received axillary radiation therapy and that the two procedures are equa lly effective. All chemotherapy combinations were assumed to be equally eff icacious. Results: The largest benefits from ALND are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-nega tive women, almost all of whom would receive adjuvant chemotherapy. When ad justed for quality of life (QOL), ALND may have an overall negative impact. In general, the benefits of ALND increase with the expected severity of ad juvant therapy on QOL. Conclusion: Our model quantifies the benefits of ALND and assists decision making by patients and physicians. The results suggest that the routine use of ALND in breast cancer patients should be reassessed and may not be nece ssary in many patients. J Clin Oncol 17:1465-1473. (C) 1999 by American Soc iety of Clinical Oncology.