The Attitudes of Brazilian Breast Surgeons on Axillary Management in Early Breast Cancer-10 Years after the ACOSOG Z0011 Trial First Publication

Ann Surg Oncol. 2022 Feb;29(2):1087-1095. doi: 10.1245/s10434-021-10812-6. Epub 2021 Sep 27.

Abstract

Purpose: To evaluate the impact of the ACOSOG Z0011 trial on axillary breast cancer surgery management in Brazil following publication of that study (2010) and again in 2020.

Patients and methods: A survey of members of the Brazilian Society of Mastology.

Results: Of 1627 breast surgeons, 799 (49.1%) completed and returned the questionnaire. For patients with the Z11 inclusion criteria, following detection of a positive sentinel lymph node (SLN), axillary dissection (AD) was recommended by 99.2% of respondents before publication of the study, 47.5% in 2010 and 18.5% in 2020 (p < 0.001). In breast-conserving surgery, if there were micro-metastases, 2.6% would perform AD, 30.3% axillary radiotherapy, and 67.1% no additional axillary treatment, while with macro-metastases, these proportions were 21.3%, 52.2%, and 26.5%, respectively. In cases of mastectomy and of nodal extracapsular extension, 43.4% and 36% of surgeons, respectively, recommended AD. For clinically negative axilla and suspicious findings at ultrasonography, 69% of the surgeons would apply the Z11 approach. Most applied the Z11 criteria in cases of younger patients (83.6%) and triple-negative and/or HER2 positive tumors (74%). AD was significantly more likely to be recommended by surgeons who did not work in academic institutes, who worked in locations other than capital cities, who were not board-certified, and who were ≥ 50 years old.

Conclusions: This survey revealed substantial changes in axillary surgery management in cN0/pathologically positive SLN, particularly following publication of the updated Z11 results and other similar studies. A better education environment and long-term follow-up were factors associated with the incorporation of Z11-related changes in practice.

Keywords: Axillary lymph node dissection; Breast conserving surgery; Breast neoplasm; Sentinel lymph nodes.

MeSH terms

  • Attitude
  • Axilla
  • Brazil
  • Breast Neoplasms* / surgery
  • Clinical Trials as Topic
  • Female
  • Humans
  • Lymph Node Excision
  • Lymph Nodes / surgery
  • Lymphatic Metastasis
  • Mastectomy
  • Mastectomy, Segmental
  • Middle Aged
  • Sentinel Lymph Node Biopsy
  • Surgeons*