Eduardo Camargo Millen1, Francisco Pimentel Cavalcante2, Felipe Zerwes3, Guilherme Novita4, Alessandra Borba Anton de Souza5, João Henrique Penna Reis6, Helio Rubens de Oliveira Filho7, Luciana Naíra de B L Limongi8, Barbara Pace Silva de Assis Carvalho9, Adriana Magalhães de Oliveira Freitas10, Monica Travassos Jourdan11, Vilmar Marques de Oliveira12, Ruffo Freitas-Junior13. 1. Breast Unit, Leblon Medical Center, Rio de Janeiro, Brazil. eduardomillen@gmail.com. 2. Breast Unit, Fortaleza General Hospital (HGF), Fortaleza, Brazil. 3. School of Medicine, Pontificia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil. 4. Breast Unit, Hospital Israelita Albert Einstein, América Serviços Médicos, São Paulo, Brazil. 5. Breast Surgery Division, PUCRS, Porto Alegre, Brazil. 6. Breast Center, Instituto Orizonti and Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil. 7. School of Medicine, Federal University of Paraná, Curitiba, PR, Brazil. 8. Breast Unit, Real Hospital Português, Recife, Brazil. 9. Breast Unit, Pace Hospital, Belo Horizonte, Brazil. 10. Breast Unit, Larmony Mastologia, Florianópolis, Brazil. 11. Breast Unit, Samaritano Botafogo (Américas Serviços Médicos), Rio de Janeiro, Brazil. 12. School of Medical Sciences, Santa Casa de São Paulo, Head of the Breast Unit, Santa Casa de São Paulo, São Paulo, Brazil. 13. Department of Obstetrics and Gynecology, CORA Advanced Center for Diagnosis of Breast Cancer, Federal University of Goiás, Goiânia, Brazil.
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.
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.
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