Who gets sentinel lymph node biopsy, versus axillary lymph node dissection?

It seems nonclinical factors, including sociodemographic characteristics and insurance status, are largely making the call. A retrospective, population-based study using data from a hospital-based cancer registry finds that while use of sentinel lymph node biopsy (SLNB) has increased from 26.8% in 1998 to 65.5% in 2005, it is reserved largely for younger, white, socioeconomically advantaged women with private medical insurance and high school diplomas.

In an analysis involving almost 500,000 women with early breast cancer, researchers calculated that those aged 72 years and older are about 20% less likely to receive SLNB versus axillary lymph node dissection (ALND) than those aged 51 years and younger (OR 0.80, 95% CI, 0.78 to 0.92). Similarly, African Americans and those who have no health insurance are about 24% less likely to receive the procedure than whites and those with private insurance, respectively (OR 0.76, 95% CI, 0.74–0.78 and OR 0.77, 95% CI, 0.73–0.80, respectively). Those with Medicaid (OR 0.81, 95% CI, 0.78–0.84) and those with Medicare younger than 65 years (OR 0.83, 95% CI, 0.80–0.87) are both about 20% less likely to receive the procedure than those with private insurance. And those who live in a zip code with a lower proportion of high school graduates (OR 0.88, 95% CI, 0.86–0.89), with lower median incomes (OR 0.79, 95% CI, 0.77–0.81), or who are receiving treatment at a facility other than a large teaching or research hospital (OR 0.84, 95% CI, 0.82–0.86), are all less likely to receive SLNB than ALND.

SLNB, a less invasive procedure than ALND, has been recommended by the American Society of Clinical Oncology as an appropriate alternative when a patient has clinically negative axillary lymph nodes.

Chen AY, Halpern MT, Schrag NM, et al. Disparities and trends in sentinel lymph node biopsy among early-stage breast cancer patients (1998–2005). J Natl Cancer Inst. 2008;100:462-474.