Decreasing rates of axillary lymph node dissections over time: Implications for surgical resident exposure and operative skills development

Abstract

Background: Sentinel lymph node biopsy has supplanted axillary lymph node dissection (ALND) in clinically node-negative breast cancer and select node-positive disease. We hypothesized a decreasing rate of both ALND and resident exposure over time.

Methods: We identified women with clinical Stage I-III breast cancer in the National Cancer Data Base (2004-2014). Adjusted multivariate logistic regression was used to estimate the effect of various factors on receipt of ALND. Yearly procedural rates for residents were extracted from surgical case log reports for comparison against procedural rates.

Results: 1,131,363 patients were identified; 255,306 received ALND, 876,057 underwent non-ALND management. ALND rates declined from 2004 (32%) to 2014 (16%, p < 0.001), with the largest decline occurring between 2010 and 2011 (24%-20%). After adjustment, this effect was maintained, with ALND rates decreasing with each additional year (OR = 0.90, 95% CI 0.89-0.90). Resident procedure volumes similarly declined from 1999 to 2017 (p < 0.001).

Conclusions: Significant declines in both ALND rates and procedural volume in residency may impact outcomes, as ALNDs are being performed in ever more challenging oncologic scenarios by potentially less-experienced surgeons.

Keywords: Axillary lymph node dissection; Breast cancer; Graduate medical education; Operative competency; Surgical volume.