Original article
Pooled long-term outcomes from two randomized trials
of axillary node sampling with axillary radiotherapy versus
axillary node clearance in patients with operable node-positive
breast cancer
A. U. Bing1 , G. R. Kerr4 , W. Jack1 , U. Chetty1 , L. J. Williams2 , A. Rodger1 and J. M. Dixon1,3
1
Edinburgh Breast Unit, 2 Centre for Population Health Sciences and 3 Breast Cancer Now Research Unit, University of Edinburgh, and 4 Oncology
Department, Western General Hospital, Edinburgh, UK
Correspondence to: Miss A. U. Bing, Edinburgh Breast Unit, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
(e-mail: [email protected])
Background: The aim was to determine long-term overall, breast cancer-specific and metastasis-free
survival as well as axillary relapse rate from a pooled analysis of two randomized trials in women with
operable breast cancer. These trials compared axillary node sampling (ANS), combined with axillary
radiotherapy (AXRT) if the sampled nodes were involved, with axillary node clearance (ANC).
Methods: Data from two clinical trials at the Edinburgh Breast Unit that randomized patients between
1980 and 1995 were pooled. Long-term survival was analysed using Kaplan–Meier curves and Cox
regression, with separate analyses for patients with node-positive (ANS + AXRT versus ANC) and
node-negative (ANS versus ANC) disease.
Results: Of 855 women randomized, 799 were included in the present analysis after a median follow-up
of 19⋅4 years. Some 301 patients (37⋅7 per cent) had node-positive disease. There was no evidence of a
breast cancer survival advantage for ANS versus ANC in patients with node-negative disease (hazard ratio
(HR) 0⋅88, 95 per cent c.i. 0⋅58 to 1⋅34; P = 0⋅557), or for ANS + AXRT versus ANC in those with nodepositive breast cancer (HR 1⋅07, 0⋅77 to 1⋅50; P = 0⋅688). There was no metastasis-free survival advantage
for ANS versus ANC in patients with node-negative tumours (HR 1⋅03, 0⋅70 to 1⋅51; P = 0⋅877), or ANS
+ AXRT versus ANC in those with node-positive disease (HR 1⋅03, 0⋅75 to 1⋅43; P = 0⋅847). Node-negative
patients who underwent ANS had a higher risk of axillary recurrence than those who had ANC (HR 3⋅53,
1⋅29 to 9⋅63; P = 0⋅014). Similarly, among women with node-positive tumours, the risk of axillary
recurrence was greater after ANS + AXRT than ANC (HR 2⋅64, 1⋅00 to 6⋅95; P = 0⋅049).
Conclusion: Despite a higher rate of axillary recurrence with ANS combined with radiotherapy to the
axilla, ANC did not improve overall, breast cancer-specific or metastasis-free survival. Axillary recurrence
is thus not a satisfactory endpoint when comparing axillary treatments.
Presented to the Miami Breast Cancer Conference, Miami, Florida, USA, February 2015, and to the Association of
Breast Surgery Conference and Annual General Meeting, Bournemouth, UK, June 2015; published in abstract form as
Eur J Surg Oncol 2015; 41: S21
Paper accepted 25 August 2015
Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9952
Introduction
Management of the axilla in invasive breast cancer remains
an area of ongoing controversy and debate. For many years
it was practice for patients with invasive cancer to have an
axillary lymph node clearance (ANC) regardless of whether
nodes were thought to be involved before surgery1,2 .
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
ANC carries considerable morbidity in terms of lymphoedema, pain, damage to the intercostobrachial nerve, and
interference with shoulder movement3 – 5 . Axillary node
sampling (ANS) is a technique pioneered in the Edinburgh Breast Unit in the early 1980s. The aim was to
offer a minimally invasive operative approach to assess the
status of the axillary nodes and avoid ANC in patients
BJS 2016; 103: 81–87
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A. U. Bing, G. R. Kerr, W. Jack, U. Chetty, L. J. Williams, A. Rodger and J. M. Dixon
without histological evidence of axillary node involvement. It was a technique that others did not find easy
to learn and was therefore not widely used outside of a
few major breast units. The ANS technique was developed and validated through a series of randomized trials
and was shown to provide a minimally invasive, accurate method of assessing axillary node status6 – 8 . ANS
was superseded first by blue dye-directed sampling of the
axillary node and then by sentinel lymph node biopsy
(SLNB) using both radioisotope and blue dye9,10 . The
ALMANAC (Axillary Lymphatic Mapping Against Nodal
Axillary Clearance) trial5 showed less arm morbidity and
better quality of life after SLNB compared with ANC,
with similar morbidity for both ANS and SLNB. The
reduction in morbidity is the major reason why SLNB is
now used widely in patients with clinically node-negative
disease.
The move to fewer axillary clearance operations has
been shown to be safe, at least in the first decade after
treatment, with equivalent survival and local recurrence
rates for SLNB compared with ANC among women
without axillary node involvement. Even in node-positive
patients the routine use of ANC is now being questioned.
In patients with one or two involved nodes on SLNB,
having breast-conserving surgery and whole-breast radiotherapy, the American College of Surgeons Oncology
Group (ACOSOG) Z0011 trial11 showed no improvement in axillary recurrence rates or overall survival
for ANC compared with SLNB alone. Recently the
AMAROS (After Mapping of the Axilla: Radiotherapy
Or Surgery) trial has shown that axillary radiotherapy
(AXRT) gives short-term outcomes equal to those of
ANC in patients with involved nodes on SLNB. Although
the National Institute for Health and Care Excellence
(NICE)12 still recommends ANC for patients with axillary
lymph node-positive breast cancer, American Society
of Clinical Oncology (ASCO) guidelines13 state that
patients with one or two positive nodes undergoing
breast-conserving surgery and whole-breast radiotherapy, who fulfil Z0011 entry criteria, do not require
routine ANC.
Over 30 years ago the Edinburgh Breast Unit initiated two randomized clinical trials (RCTs)6,7 comparing
ANC with ANS followed by AXRT if the sampled nodes
were involved. Updated results from these two cohorts are
presented here, providing the first long-term data comparing ANS with or without AXRT versus ANC. Results
are presented for overall survival, breast cancer-specific
survival, metastasis-free survival and axillary recurrence
patterns among women with a follow-up of more than
20 years since treatment.
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
Methods
Two consecutive RCTs6,7 on ANS versus ANC were used in
the pooled analysis. The first trial7 enrolled patients having
mastectomy and the second6 included patients treated by
breast-conserving surgery. Approval was sought for both
trials from a local ethics committee, and informed consent
was given by all patients.
The inclusion criteria for the two trials were: operable
invasive breast cancer (T1–T3, N0–N1, M0), and patient
suitable for both surgery and radiotherapy. The exclusion
criteria were: inoperable or clinically multicentric tumour,
ductal carcinoma in situ, fixed axillary nodes, previous invasive carcinoma (except skin basal cell carcinoma), Paget’s
disease of the nipple and male sex. Patients aged over
70 years were also excluded from the breast conservation trial6 . All patients underwent investigation to exclude
metastatic disease, including liver ultrasonography, skeletal
scintigraphy, radiography of the chest, abdomen and pelvis,
and haematological and liver function testing. The study
endpoints were: overall survival, breast cancer-specific survival, time to locoregional relapse and time to distant
metastasis.
Axillary surgery
In ANS the surgeon identified four palpable axillary lymph
nodes. These nodes were taken primarily from level I in
the lower axilla; the number of nodes excised ranged from
two to eight. Patients randomized to ANC had all nodes
removed up to and including level III. Node involvement
was determined histologically following ANS or ANC.
Axillary radiotherapy
Patients with node-positive disease found after ANS were
treated with AXRT. AXRT was given to all node-positive
patients who had ANS, apart from five who were randomized to the no-radiotherapy arm of the Scottish Conservation Trial; these patients were omitted from the present
analysis. Patients who underwent ANC and who had
involved nodes did not receive radiotherapy.
In the breast conservation trial, regional lymphatics were
treated by a direct anterior field covering the axilla and
supraclavicular fossa with a posterior axillary boost, bringing the mid-axillary dose to 4500 Gy in 20 fractions over
4 weeks6 .
In the mastectomy trial, radiotherapy included the
ipsilateral internal mammary chain, shoulder fields and
supraclavicular fossa7 . During the course of the trial
modifications were made to the radiotherapy treatment,
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Axillary node sampling with axillary radiotherapy versus axillary node clearance in operable node-positive breast cancer
the total dose being reduced from 4500 Gy in 20 fractions
to 4000 Gy in ten fractions over 4 weeks.
Systemic therapy
All patients received standard postoperative adjuvant
chemotherapy or endocrine treatment for the time interval of the study. Chemotherapy mainly comprised a
cyclophosphamide, methotrexate and fluorouracil regimen
or Adriamycin (doxorubicin)-based regimens. Treatments
were based on the results of pathology, including axillary
lymph node histology and hormone receptor status. Some
oestrogen receptor (ER)-negative patients did not have
chemotherapy, and many ER-negative patients received
tamoxifen because of the belief at the time that these
patients might also benefit from such treatment. In addition, not all women with ER-positive cancers received
tamoxifen. Some premenopausal women with ER-positive
cancers had an oophorectomy.
Follow-up
Patients were followed up in outpatient clinics in the oncology and breast surgery departments, every 3 months for
2 years, 6 monthly from years 2 to 5 and annually thereafter.
Patients who were disease-free at 10 years were discharged
to primary care. Follow-up for these patients was by yearly
contact with the general practitioner.
Data available from the pooled trials
Demographic and clinical information available included:
age, type of breast cancer, TNM stage, tumour size on
pathology and lymph node status (number of nodes excised,
number of positive nodes), type of axillary operation, radiotherapy to the axilla, radiotherapy to the breast, ER status,
and adjuvant systemic therapy.
Data were updated from previous publications using
existing departmental databases, electronic patient records
and case notes. Cause of death was established from death
certificates archived at Register House, Edinburgh. Breast
cancer was considered to be the cause of death only if listed
within part 1 of the death certificate.
Statistical analysis
Kaplan–Meier survival curves were used to show survival
and relapse rates. Cox survival models were used to generate hazard ratios (HRs) and 95 per cent c.i. The proportional hazards assumption was tested and found to hold in
all analyses. The log rank test was used to test for equality
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
83
of survival distributions and to assess any statistically significant differences between randomized groups. All tests
were two-sided. A limited number of subgroup analyses
were performed to generate hypotheses. Data analysis was
carried out by an independent statistician using SPSS® for
Windows® version 19.0 (IBM, Armonk, New York, USA).
Results
In total, 855 women with invasive breast cancer were randomized to either ANC (424) or ANS ± AXRT (431) in
the two trials between 1980 and 1995 (Fig. 1). Follow-up
to death or at least 20 years was available for 799 patients;
only 56 patients (6⋅5 per cent) were lost to follow-up,
mostly owing to change of address. The median and mean
follow-up times were 19⋅4 and 19⋅9 years respectively.
Node-positive disease
Information was available for 301 women with
node-positive disease (37⋅7 per cent of all patients). This
excludes patients randomized to the no-radiotherapy arm
of the Scottish Conservation Trial and patients for whom
the number of nodes was not recorded. This node-positive
group was subdivided according to number of positive
lymph nodes (Table 1).
Overall survival
The overall median survival time in these patients was
estimated at 13⋅8 years (ANC 13⋅2 years, ANS + AXRT
14⋅4 years). There was no difference in overall survival
between ANC and ANS + AXRT (P = 0⋅876, log rank test).
There was no evidence to suggest that ANS + AXRT gave
a survival advantage or disadvantage over ANC in patients
with node-positive disease (HR 0⋅98, 95 per cent c.i. 0⋅75
to 1⋅28; P = 0⋅876).
There was no difference in survival between patients with
one versus two to four involved nodes (P = 0⋅159). However,
patients with five to nine (HR 1⋅73, 1⋅11 to 2⋅71; P = 0⋅016)
and ten or more (HR 2⋅45, 1⋅51 to 3⋅98; P < 0⋅001) involved
nodes had significantly higher risks of death than patients
with only one node involved.
Age over 65 years (HR 2⋅18, 1⋅51 to 3⋅15; P < 0⋅001) and
at least ten involved axillary nodes (HR 2⋅45, 1⋅51 to 3⋅98;
P < 0⋅001) were the only significant predictors of overall
survival. Axillary surgery was not found to be a significant
predictor of death once other factors had been accounted
for in patients with node-positive tumours (P = 0⋅254).
Breast cancer-specific survival
In patients with axillary lymph node-positive disease, 137
(62⋅0 per cent) of the 221 deaths were from breast cancer.
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A. U. Bing, G. R. Kerr, W. Jack, U. Chetty, L. J. Williams, A. Rodger and J. M. Dixon
Randomized
n = 855
Axillary node
sampling n = 431
Axillary node-positive
Radiotherapy to
axilla n = 148
Fig. 1
Axillary node-negative
No further
treatment n = 283
Axillary node
clearance n = 424
Axillary node-positive
No further
treatment n = 164
Axillary node-negative
No further
treatment n = 260
Initial randomization of patients to axillary node sampling or axillary node clearance
Number of positive nodes among women with axillary
involvement
1·0
No. of positive nodes
1
2–4
5–9
≥ 10
Probability of being axillary recurrence-free
Table 1
No. of patients (n = 301)
106 (35⋅2)
137 (45⋅5)
34 (11⋅3)
24 (8⋅0)
There was no evidence to suggest that ANS + AXRT gave
a survival advantage or disadvantage over ANC in terms of
death from breast cancer (HR 1⋅07, 95 per cent c.i. 0⋅77 to
1⋅50; P = 0⋅688).
Axillary relapse
In women with node-positive disease, a difference in time
to axillary recurrence between ANC and ANS + AXRT was
shown (P = 0⋅041, Mantel–Cox test) (Fig. 2). Patients who
had ANS + AXRT were more than twice as likely as those
having ANC to develop an axillary recurrence (HR 2⋅64, 95
per cent c.i. 1⋅00 to 6⋅95; P = 0⋅049). Numbers of axillary
recurrences, by type of axillary surgery and node status,
are detailed in Table 2. There were no survivors among
patients who had an axillary relapse after ANC at a median
follow-up of 19⋅4 years.
Time to metastases
There was no evidence to suggest that ANS + AXRT had
a metastasis-free survival advantage or disadvantage over
ANC (HR 1⋅03, 95 per cent c.i. 0⋅75 to 1⋅43; P = 0⋅847).
As expected, patients with a greater number of positive
nodes had a significantly higher risk of metastasis. For
patients with between five and nine involved nodes the HR
for an axillary relapse was 2⋅24 (95 per cent c.i. 1⋅33 to 3⋅76;
P = 0⋅002) compared with those with fewer involved nodes.
For those with at least ten involved nodes the HR was 3⋅45
(1⋅99 to 5⋅97; P < 0⋅001) versus patients with fewer than ten
involved nodes.
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
0·8
0·6
ANC
ANS
0·4
0·2
0
5
10
15
20
Time after first surgery (years)
No. at risk
ANC
165
ANS
136
121
99
89
77
79
64
62
45
Time to axillary recurrence after axillary surgery in patients
with node-positive disease. ANC, axillary node clearance; ANS,
axillary node sampling
Fig. 2
There was no evidence to suggest that axillary surgery
had any impact on time to metastasis once node status had
been taken into account in either univariable (P = 0⋅847) or
multivariable (P = 0⋅090) analysis.
Node-negative disease
A total of 498 women (62⋅3 per cent) had node-negative
disease. None of these patients had AXRT. The overall median survival time for this group was estimated at
22⋅1 years, 22⋅1 years for those who underwent ANC and
22⋅0 years for women who had ANS.
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Axillary node sampling with axillary radiotherapy versus axillary node clearance in operable node-positive breast cancer
Number of patients with axillary recurrence subdivided
by node status and type of axillary surgery
85
1·0
Table 2
Axillary recurrence
Yes (n = 40)
Total (n = 799)
255
159
5 (1⋅9)
6 (3⋅6)
260
165
222
123
16 (6⋅7)
13 (9⋅6)
238
136
0·8
Breast cancer-specific survival
Axillary node clearance
Node-negative
Node-positive
Axillary node sampling
Node-negative
Node-positive
No (n = 759)
Values in parentheses are percentages.
Overall survival
In patients with lymph node-negative disease there was no
significant difference in overall survival for those treated by
ANC versus ANS (P = 0⋅748). Age over 65 years (HR 2⋅63,
95 per cent c.i. 1⋅98 to 3⋅52; P < 0⋅001) and type of surgery
(mastectomy versus breast conservation) (HR 1⋅34, 1⋅05
to 1⋅74; P = 0⋅021) were significant predictors of overall
survival in multivariable analysis. Axillary surgery was not
a significant predictor of death once other factors had been
accounted for (P = 0⋅791).
0·6
0·4
ANC, N–
ANC, N+
ANS, N–
ANS, N+
0·2
0
5
10
15
20
Time to first surgery (years)
No. at risk
ANC, N–
ANC, N+
ANS, N–
ANS, N+
260
165
238
136
229
124
214
103
197
92
194
80
175
79
163
66
142
62
132
46
Breast cancer-specific survival, by axillary surgery and node
status. ANC, axillary node clearance; N–, node-negative; N+,
node-positive; ANS, axillary node sampling
Fig. 3
Breast cancer-specific survival
There was no significant difference in death from
breast cancer after ANS versus ANC in patients with
node-negative disease (HR 0⋅88, 95 per cent c.i. 0⋅58 to
1⋅34; P = 0⋅557).
Death from breast cancer was significantly less likely in
patients with negative axillary nodes than in women with
axillary node-positive disease (P < 0⋅001), with no evidence
of any effect of axillary treatment type (Fig. 3).
Axillary relapse
There were no new local recurrences after the first decade
in patients with node-negative disease. All axillary recurrences in the ANC category occurred within the first
4 years, and those in the ANS group within 9 years. There
was a significant difference in time to axillary recurrence
between the ANC and ANS groups (P = 0⋅009). The risk
of axillary relapse was significantly higher after ANS than
ANC (3⋅53, 95 per cent c.i. 1⋅29 to 9⋅63; P = 0⋅014). In
the Cox regression model, which included type of breast
surgery and tumour size, there was no evidence that any
variable other than axillary surgery affected the time to
axillary recurrence.
In the whole cohort, the annual risk of axillary recurrence
increased from year to year. This was not, however, statistically significant (P = 0⋅633). Neither was relapse linear
over time (Table 3). Between 1983 and 1987, no patients had
surgery owing to the timing of the two trials6,7 .
© 2015 BJS Society Ltd
Published by John Wiley & Sons Ltd
Rates of axillary recurrence in relation to node status and
year of surgery
Table 3
Axillary recurrence
Node-negative disease
1980–1983
1987–1990
1991–1995
Whole study
Node-positive disease
1980–1983
1987–1990
1991–1995
Whole study
All patients
1980–1983
1987–1990
1991–1995
Whole study
Proportion of patients
5-year rate (%)
8 of 232
6 of 105
7 of 161
21 of 498
1⋅8 (0⋅1, 3⋅5)
4⋅9 (0⋅7, 9⋅1)
3⋅2 (0⋅4, 5⋅9)
2⋅9 (1⋅4, 4⋅4)
8 of 163
5 of 57
6 of 81
19 of 301
2⋅1 (0, 4⋅5)
6 (0, 13)
8 (2, 14)
4⋅5 (2⋅0, 6⋅9)
16 of 395
11 of 162
13 of 242
40 of 799
1⋅9 (0⋅5, 3⋅3)
5⋅3 (1⋅7, 8⋅8)
4⋅7 (2⋅0, 7⋅4)
3⋅4 (2⋅1, 4⋅7)
Values in parentheses are 95 per cent c.i.
Time to metastasis
There was no evidence to suggest that the metastasis-free
survival time differed between ANS and ANC groups in
patients with node-negative disease (HR 1⋅03, 95 per cent
c.i. 0⋅70 to 1⋅51; P = 0⋅877).
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A. U. Bing, G. R. Kerr, W. Jack, U. Chetty, L. J. Williams, A. Rodger and J. M. Dixon
Discussion
The present pooled analysis from two RCTs provides
long-term follow-up data for 799 patients randomized
to two different methods of axillary treatment. Median
follow-up was 19⋅4 years, with follow-up to death or at least
20 years for over 90 per cent of the cohort.
This study showed no significant differences between
ANC and ANS, combined with AXRT if the sampled nodes
were involved, in terms of overall, breast cancer-specific
and metastasis-free survival in patients with operable
invasive breast cancer (T1–T3, N0–N1, M0). The lack
of difference in breast cancer-specific outcomes adds to
the data on metastasis-free survival, and confirms that the
type of axillary treatment does not affect survival.
Most axillary recurrences (39 of 40) occurred in the first
10 years after commencing treatment, with the final local
recurrence occurring in the 18th year. This is of importance for studies whose primary endpoint is locoregional
events, such as the ALMANAC trial5 and the new POSNOC (POsitive Sentinel NOde: adjuvant therapy alone
versus adjuvant therapy plus Clearance or axillary radiotherapy) UK SLNB study. Follow-up in excess of 5 years
is required if the primary endpoint is axillary recurrence,
as in the POSNOC study. The AMAROS trial by Rutgers and colleagues compared SLNB + AXRT with ANC
in women with a positive SLNB, and showed no difference in overall disease-free survival at 5 years between
the two groups. In the present study, the axillary recurrence rate was higher with ANS (with AXRT if sampled
nodes were involved) than ANC in both node-negative
and node-positive patients. However, this increased rate of
axillary relapse did not have an adverse effect on survival.
There are a number of reasons for this. First, ANS is
not easy to learn, and there is the potential for sampling
error. The operations in the RCTs were performed by a
range of consultant and trainee surgeons, which might have
increased the risk of positive nodes being missed. However,
in a paper by Steele and co-workers14 , 417 patients were
allocated randomly to ANS or ANC. At the completion
of the procedure, 135 patients who had undergone ANS
were randomized to ANC or no further surgery. No patient
had positive nodes on ANC that were negative on ANS,
confirming the accuracy of the sampling technique when
performed correctly. Apart from the latter study, there are
limited data on the false-negative rate of ANS. In contrast,
there is huge amount of data on the false-negative rate of
SLNB, with a meta-analysis15 reporting a rate of 7⋅3 per
cent; the rate for ANS is likely to be higher.
Second, in the present study the number of nodes sampled ranged from two to eight. Many of the axillary recurrences in patients with negative ANS could have been due
© 2015 BJS Society Ltd
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to involved nodes being missed by the surgeon. In studies of ANS and SLNB, the more nodes that are removed
and examined, the lower the false-negative rate. Additionally, the number of nodes involved helps guide decisions
regarding adjuvant systemic treatment, which would have
influenced the use of adjuvant systemic therapy in the RCTs
analysed here6,7 . Patients having ANS had fewer nodes
sampled, which may have resulted in less adjuvant therapy being given. This difference was small in reality, but
the lack of adjuvant therapy in women with a false-negative
ANS could have influenced the rate of axillary recurrence.
There were no long-term survivors among patients who
had an axillary relapse after ANC. This demonstrates that
an axillary recurrence is salvageable with further axillary
surgery with or without AXRT after ANS or SLNB, but
relapse after ANC is biologically quite different. Patients
with clinically involved nodes (N1) were eligible to enter
the RCTs6,7 , so some recurrences in the ANS groups will
have represented residual axillary disease not controlled
by AXRT. ANC was an option for such women, many of
whom did well after this procedure.
The rates of axillary recurrence were higher in this series
than in the Z001111 and AMAROS trials. These differences are likely to be explained by the more advanced stage
of disease in the present trials and the systemic therapy
administered. Not all ER-positive patients in the present
cohort received hormone therapy, and not all ER-negative
patients had chemotherapy. There was a significantly lower
rate of axillary recurrence among patients who did receive
endocrine therapy, The effects of improved systemic
therapy in terms of reducing local and regional recurrence have been well documented in other randomized
trials11,16 .
In this study, node status had a great influence on
long-term outcomes, whereas the type of nodal treatment
did not. The greater the number of positive lymph nodes
involved, the greater the risk of death. Only age and the
number of nodes were significant predictors of time to
death. This reinforces previous findings11,16 – 18 that type
of axillary treatment is not a predictor of survival. The
importance of the present study lies in its demonstration
that axillary treatment does not influence long-term
survival, despite an increased rate of axillary recurrence
with ANS (with or without AXRT). There is clearly no
survival benefit to a more aggressive surgical approach to
the axilla.
Axillary treatments are not without morbidity and,
although this was not recorded routinely, detailed morbidity data for patients having breast-conserving surgery
were reported previously6 . In this group lymphoedema
rates were significantly higher with ANC than ANS
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BJS 2016; 103: 81–87
Axillary node sampling with axillary radiotherapy versus axillary node clearance in operable node-positive breast cancer
with or without AXRT, although AXRT significantly
influenced shoulder morbidity and reduced the range of
some shoulder movements. The AMAROS trial13 has
also confirmed the much higher rates of lymphoedema
with ANC. In AMAROS there was, however, no effect of
AXRT on shoulder movement. Since the trials included in
the present study, radiotherapy techniques and planning
have improved, and techniques to avoid shoulder capsule
irradiation are now routine, which probably explains the
difference in shoulder morbidity in the present study and
AMAROS trial.
This study raises the question of whether women having
whole-breast radiotherapy and are deemed to require
axillary treatment should be offered AXRT rather than
ANC because it produces similar long-term survival
outcomes, but results in less significant morbidity and a
much lower rate of lymphoedema. A selective approach
to the axilla is supported by the present findings, which
show that axillary treatment does not influence long-term
survival.
Disclosure
The authors declare no conflict of interest.
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