African American women less likely to receive improved surgical procedure for breast cancer
MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention. Providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin and today we'll be talking about a study that was released at the San Antonio Breast Cancer Symposium that finds that African-American women with early stage invasive breast cancer are 12% less likely than Caucasian women to get a minimally invasive technique known as an axillary sentinel lymph node biopsy. And here to discuss this study today are two guests and authors of the study, Dalliah Black, who is an Assistant Professor of Breast Surgical Oncology. And Dr. Benjamin Smith, also an Assistant Professor of Radiation Oncology, both here at MD Anderson. Dr. Black did these study findings surprise you at all?
Dr. Dalliah Black: They were surprising. It's interesting because the disparity that we found between Black patients and White patients persisted between 2002 and 2007. In both groups of patients, there was an increased uptake in sentinel node biopsy use. However, the disparity still persisted at 2007. It's also interesting because Black patients who had an axillary node dissection had a higher risk of lymphedema, which is a long-term complication of the bigger surgery, the axillary node dissection.
Lisa Garvin: Let's talk about what are sentinel lymph nodes? So let's get into the anatomy of this first.
Dr. Dalliah Black: Sure. So a sentinel lymph node is the guarding lymph node in the axilla that trains the breast. So if a patient has an invasive breast cancer, that is the first way to stage the breast cancer. So the sentinel node is the guarding lymph node. And you can identify that lymph node because it selectively takes up radioactivity or blue dye.
Lisa Garvin: Now -- and what is the difference between a sentinel lymph node biopsy and an axillary lymph node biopsy?
Dr. Dalliah Black: So a sentinel node biopsy is a minimally invasive surgical technique. So you still make a surgical incision in the axilla and you typically remove between one to two or three lymph nodes. An axillary node dissection means removing all of the lymph nodes in the axilla. So level one; level two lymph nodes in the axilla. So it's a bigger surgery with higher short-term and long-term complications.
Lisa Garvin: And isn't it true that the more lymph nodes you remove, the higher the risk for lymphedema?
Dr. Dalliah Black: Correct. So if a patient has a sentinel node biopsy, the chance of having lymphedema is about 5% to 7%. If someone has an axillary node dissection, the chance of lymphedema is much higher; about 20% to 40%.
Lisa Garvin: Now how did you go about collecting the data for this study?
>> Dr. Dalliah Black: So this is a retrospective, SEER-Medicare database study. And we evaluated -- initially there are over 51,000 patients in this study. Of those patients we evaluated over 31,000 women who had pathologic node-negative breast cancer with a code for axillary surgery.
Lisa Garvin: Dr. Smith, what can you tell us about the initial results of the study?
Dr. Benjamin Smith: Right, so all the patients in the study had no evidence of cancer spread to their lymph nodes, which means that all of these patients could have undergone a sentinel lymph node biopsy as an appropriate form of initial surgical therapy to evaluate the axillary lymph nodes. And we found that patients in this study were increasingly likely to receive a sentinel lymph node biopsy for evaluating their axillary lymph nodes as the years progressed in our study. So patients in 2007 were much more likely to receive sentinel lymph node biopsies, compared to axillary lymph node dissection, compared to patients diagnosed in the early 2000's. And yet despite continued increase in use of sentinel lymph node biopsy, for each year Black or African-American patients were still less likely to undergo sentinel lymph node biopsy. Conversely, that means that the Black patients were more likely to undergo axillary lymph node dissection, which is a procedure that carries more significant, long-term morbidity, such as the risk of lymphedema.
Lisa Garvin: And were you able to measure the rates of lymphedema in this population?
Dr. Benjamin Smith: Yeah. So we were able to look at diagnosis claims codes for lymphedema in this patient population, and we found that patients who underwent an axillary lymph node dissection had a higher likelihood of a code for lymphedema than patients who underwent a sentinel lymph node biopsy. And this data said the likelihood of a code for lymphedema occurring any time during the first five years of diagnosis was 12% in patients who underwent an axillary lymph node dissection, compared to about 7% in patients who underwent a sentinel lymph node biopsy.
Lisa Garvin: So it sounds like there was a slight improvement over the study period. So it sounds like maybe the message is slowly getting out about sentinel lymph node biopsy?
Dr. Dalliah Black: Correct. That's an interesting point. So it appears that the utilization of sentinel lymph node biopsy in African-American women lagged behind Caucasian women for about two to three years. So there is a lag in the uptake of sentinel node technique in the space of biopsy.
Dr. Benjamin Smith: Right. So the use of sentinel node biopsy in Blacks in 2007 was about equal to the use of sentinel lymph node biopsy in Whites in about 2004 or 2005. So it was being disseminated to Black patients, but they were just lagging behind about two to three years, which is interesting.
Lisa Garvin: Can we attribute this to socioeconomic issues? Or health access issues?
Dr. Dalliah Black: Alright, so we don't exactly know because this is a claims database retrospective study. So we don't know the reasons behind the disparities, but they're likely multifactorial. Right, so there may be socioeconomic differences. And we did some preliminary data looking at census track, socioeconomic status, and patients were less likely to receive a sentinel lymph node biopsy in lower socioeconomic tracks. Lower education was also associated with the decreased use of sentinel node biopsy, and lower surgeon density.
Lisa Garvin: Now as far as sentinel lymph node biopsies, are these done outside of a cancer center? I mean do primary care doctors do these? Or --
Dr. Dalliah Black: No. So that's a surgical procedure, so a surgeon would do it. But there are many general surgeons who take care of breast cancer patients. So a general surgeon should be able to perform this procedure as well as general surgical oncologists and breast surgical oncologists.
Lisa Garvin: But is perhaps there a learning curve out there in ceratin medical populations about this biopsy procedure?
Dr. Dalliah Black: So there is. So when the sentinel node biopsy technique was first being reported, as early as 1994 and 1998, and so recommendations were made from our national organizations about how a safe way for surgeons to incorporate this new technique into their practice. So it started out being a surgeon should do 30 sentinel lymph node biopsies, and also do a backup axillary node dissection to make sure they had accurately identified the sentinel node. And then after that, you should look at your complications, look at your false negative rate to make sure you hadn't missed the appropriate lymph node. And if your numbers met the guideline criteria, then you were deemed able to fly on your own and do a sentinel lymph node biopsy alone. Now this changed to 20 cases, or if you have additional fellowship training for a surgeon then you can go out and do a sentinel node biopsy. So there was an evolution in how to disseminate that new procedure to the community.
Dr. Benjamin Smith: And so we tried to account for that in our study. And we said a patient got a sentinel lymph node biopsy if there was a code that the surgeon tried to map the sentinel lymph node. And so even if a patient had a sentinel lymph node biopsy and a completion backup axillary lymph node dissection, we still said that patient had a sentinel lymph node biopsy for the purposes of our study. So we tried to account for that learning period in giving surgeons the benefit of the doubt that if they were doing a sentinel node plus that axillary dissection, that they were trying to do the right thing for their patient and offer them this new surgical therapy.
Lisa Garvin: What about insurance barriers? Is insurance coverage an issue with sentinel lymph node biopsies?
Dr. Benjamin Smith: All the patients in this study had Medicare fee-for-service coverage, so they're a fairly level playing field. Sentinel node biopsy is routinely covered by Medicare. An interesting finding of our study though, is that patients who actually had better insurance -- so patients who had Medicare plus backup Medicaid helping them to cover their deductibles and copayments were actually still less likely to have a sentinel lymph node biopsy than patients who just had garden variety fee-for-service Medicare.
Lisa Garvin: Now where do we go from here? And MD Anderson has been very good about addressing health disparities and studying health disparities. And this just seems like one more tick in the column for African-American patients, you know, as far as access and treatment and so forth. Where do we go from here Dr. Black?
Dr. Dalliah Black: We need to improve patient education and patient advocacy. So if you're diagnosed with a breast cancer, patients need to know the appropriate questions to ask their healthcare team when they arrive. We also need to approve disseminating practice guidelines to all members of the healthcare teams throughout all of our communities so that the surgeons and other breast healthcare providers will know to do the right thing hopefully.
Dr. Benjamin Smith: You know it's worth noting that my surgical colleagues looked at their own surgical database for how patients were treated at MD Anderson during the precise years of our study. And we found that about 65% of patients at MD Anderson had a sentinel lymph node biopsy, which is pretty compatible with our overall study findings. But beyond that, there was absolutely no racial disparity in use of sentinel lymph node biopsy between Black and White patients. Actually Black patients were slightly more likely to have a sentinel lymph node biopsy than White patients here at MD Anderson. And I think that just suggests if minority patients can get to a comprehensive cancer center where patients are getting appropriate care, there's probably not going to be that much of a racial disparity.
Lisa Garvin: And you know, maybe some people -- obviously those who have never had lymphedema say, well what's the big deal? I mean we're just talking about some side effects. But for women with lymphedema it is a big deal.
Dr. Dalliah Black: It can be a huge quality of life issue. And so many women work and have lots of other things to do, and if that arm is your dominant hand that you use, that can be a substantial problem for a patient. And so symptoms that women will feel or experience, you know, heaviness, swelling, it can be painful, sharp, shooting pain. And it can be persistent or transient and can get worse over time.
Lisa Garvin: And you're always having to wrap your arms and bind your arms, and yeah.
Dr. Dalliah Black: Right. Physical therapy, treatment, manual massage. There are even machines to help drain lymphatic fluid. So it can be intense depending on how severe it is.
Lisa Garvin: Are there any other potential side effects, other than lymphedema that are attached to an axillary lymph node biopsy?
Dr. Dalliah Black: Sure. So short-term complications compared to a sentinel lymph node biopsy are an increased risk of bleeding, seroma is a fluid collection underneath the arm. Increased risk of infection and long-term rarely would be an associated cancer from lymphedema -- persistent lymphedema, but that's pretty rare.
Dr. Benjamin Smith: Probably also more likely to have nerve damage or nerve numbness --
Dr. Dalliah Black: Right.
Dr. Benjamin Smith: -- in the armpit.
Dr. Dalliah Black: Correct.
Lisa Garvin: So this is very interesting news. It's a little bit disturbing but at least we're getting a finger on it. What sort of final thoughts do you have Dr. Black about this situation?
Dr. Dalliah Black: I think it's important to get the message out to patients and to healthcare providers throughout all of the communities. It's important to raise awareness and to let patients know what the current practice guidelines are. It's important to minimize disparities because they ultimately can affect a patient's quality of life and potentially survival in some aspects. Not necessarily in the sentinel node study, but in other aspects.
Lisa Garvin: Okay. Thank you both for being with us today. If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789. Or online at mdanderson.org/ask [music]. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.
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