4. Axillary

Objective: To provide information needed by patients with breast cancer (stages I and II) and their physicians when deciding whether axillary dissection should be carried out. Options: No axillary surgery; removal of all axillary lymph nodes; removal of level 1 and 2 nodes; axillary “sampling.” Outcomes: Accurate determination of stage of cancer, resulting in better-informed therapeutic decisions; reduction of recurrence in axillary lymph nodes; improved survival. Evidence: A systematic review of English language literature based on MEDLINE and CANCERLIT databases to September 1996, with nonsystematic review continued to June 1997. The nature of the evidence or opinion is classified as shown on page S2. Benefits: Optimal therapy, with maximal survival and minimal local recurrence. Harms: Increased postsurgical morbidity. Recommendations: • Removal and pathological examination of axillary lymph nodes should be standard procedure for patients with early, invasive breast cancer. • For accurate staging and to reduce the risk of recurrence in the axilla, level 1 and level 2 nodes should be removed. • Patients should be made fully aware of the frequency and severity of the potential complications of axillary dissection. • Irradiation of the axilla should carried out with caution after axillary dissection. • Omission of axillary dissection may be considered when the risk of axillary metastasis is very low or when knowledge of node status will have no influence on therapy. • Patients should be offered the opportunity to participate in clinical trials whenever possible. Validation: Initial draft guidelines were successively reviewed and revised by a writing committee, expert primary reviewers, secondary reviewers chosen from all regions of Canada and by the Steering Committee. The final document reflects a consensus of all these contributors. Sponsor: The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada. Completion date: July 1, 1997 The question of whether, and to what extent, axillary lymph nodes should be removed at the time of surgery for breast cancer does not yet have a clear-cut answer. On the one hand, surgical removal of these nodes provides important information for determining the stage of the cancer and, in addition, reduces the rate of recurrence of axillary cancer. Unfortunately, however, axillary dissection may be associated with significant long-term morbidity. Thus, the decision on whether to remove axillary nodes and how extensively to do so requires a balancing of the expected health gains versus side effects. These guidelines attempt to synthesize the available information with the objective of helping patients and their physicians make these decisions. The evidence is gathered from randomized controlled studies or cohort studies and, when such evidence is not available, expert opinion is used. The evidence is classified into 5 levels (see page S2).