At SABCS last year, in 2011, one of the memorable moments was when Dr. Laura Esserman from UCSF stood at the mic after a presentation and publicly pleaded with all the surgeons in the room to abandon routine full lymph dissection. The data on which she was commenting resolved once and for all that sentinel node biopsy should be the standard of care, providing sound diagnostic and prognostic data while improving quality of life by decreasing rates of lymphedema.
At the time, I suggested this was not news. Indeed sentinel node biopsy—a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present—has been the preferred technique for a number of years, since around 2007.
At this year’s symposium, Dr Dalliah Black presented data doing a retrospective analysis of the SEER/Medicare database studying over 31,000 women diagnosed with invasive breast cancer between 2002 and 2007 who did not have lymph node involvement and underwent a documented axillary surgical procedure.
The data shows that African American women are approximately 12% less likely than white patients to have sentinel node biopsy, thus exposing them to a more invasive surgery with higher complications, including risk of lymphedema. White women were more likely than other races to get the preferred sentinel node biopsy: 74% of white women compared to 65% of other races and 62% of African American women.
Possible reasons suggested for this disparity include lower socioeconomic status of African-American patients, less access to health care, and differences in tumor biology. However the 12% disparity held true even adjusting for a range of factors.
We know that African American women, while less likely than white women to be diagnosed with breast cancer, are more likely to die of the disease. In addition to higher mortality, African American women have higher morbidity associated with the disease. They are more likely to experience worse side effects. The result of this disparity in surgery is that African American patients have double the rate of lymphedema.
This study documents the disparity but does not provide us with a full understanding of the reasons and mechanisms by which race is an independent variable linked to sentinel node biopsy. Nonetheless, Dr Black suggests that when implementing new standards of care and practice-changing recommendations, it is important that education and outreach to practitioners happens to ensure that all patients benefit from advances in treatment.