Patterns of Care with a Positive Sentinel Node: Echoes of an Opportunity Missed

Excerpt

In this issue of Annals of Surgical Oncology, Wasif and coauthors report the results of a survey of 537 American Society of Clinical Oncology (ASCO) members that shows only 23% of surgeons and medical oncologists, and only 15% of radiation oncologists, “always” perform an axillary dissection for the finding of micrometastases in the sentinel node (SN).1 This practice is contrary to ASCO guidelines that state axillary dissection is the standard management of micrometastases in the SN.2 Documentation of a major deviation from guidelines is important, although it is possible to quibble with some of the specifics of this article. After all, the ASCO guidelines were published in 2005, and our knowledge regarding the SN procedure has increased exponentially since that time; it is not unreasonable to conclude that part of the reason the guidelines are not followed is because they are out of date. In addition, the wording of the survey question as “always” was unfortunate, since virtually nothing in breast cancer surgery is absolute. The use of the word “usually” might have provided a more accurate picture of clinical practice. However, to focus on these points is to miss the bigger questions: Why is there so much disagreement about appropriate practice? What have we learned about micrometastases and how should we deal with them? …