American College of Surgeons

View all recommendations from this society

Released September 4, 2013

Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy.

Sentinel node biopsy is proven effective at staging the axilla for positive lymph nodes and is proven to have fewer short and long term side effects, and in particular is associated with a markedly lower risk of lymphedema (permanent arm swelling).

When the sentinel lymph node(s) are negative for cancer, no axillary dissection should be performed.

When one or two sentinel nodes are involved with cancer that is not extensive in the node, the patient received breast conserving surgery and is planned to receive whole breast radiation and stage appropriate systemic therapy, axillary node dissection should not be performed.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American College of Surgeons (ACS) solicited recommendations for the ABIM Foundation’s Choosing Wisely® campaign from the Commission on Cancer, Committee on Trauma, and the Advisory Councils for Colon and Rectal Surgery, General Surgery, and Pediatric Surgery. The committees were provided with a description of the campaign’s initiative, a link to the Choosing Wiselywebsite, and published recommendations from organizations already participating in the campaign were referenced and reviewed during discussions. All of the recommendations collected from the ACS committees were reviewed, and five items were identified. The ACS’ disclosure and conflict of interest policy can be found at www.facs.org.

Participating ACS Committees:

Advisory Council for Colon and Rectal Surgery

  • Chair: Thomas E. Read, MD, FACS, Burlington, MA

Advisory Council for General Surgery

  • Chair: E. Christopher Ellison, MD, FACS, Columbus, OH

Advisory Council for Pediatric Surgery

  • Chair: Mary E. Fallat, MD, FACS, Louisville, KY
  • Immediate Past Chair: Thomas F. Tracy Jr., MD, FACS, Providence, RI

Commission on Cancer

  • Chair: Daniel P. McKellar, MD, FACS, Greenville, OH

Committee on Trauma

  • Chair: Michael F. Rotondo, MD, FACS, Greenville, NC

Sources

Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, Ashikaga T, Weaver DL, Mamounas EP, Jalovec LM, Frazier TG, Noyes RD, Robidoux A, Scarth HM, Wolmark N. Sentinel lymph-node resection compared with conventional axillary-lymph-node-dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 4 trial. Lancet Oncol. 2010 Oct;11(10):927-933.

Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, McCall LM, Morrow M. Axillary dissection vs. no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011 Feb 9;305(6):569-5.

Ashikaga T, Krag DN, Land SR, Julian TB, Anderson SJ, Brown AM, Skelly JM, Harlow SP, Weaver DL, Mamounas EP, Costantino JP, Wolmark N; National Surgical Adjuvant Breast, Bowel Project. Morbidity results for the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010 Aug 1;102(2):111-8.

Giuliano AE, Hawes D, Ballman KV, Whitworth PW, Blumencranz PW, Reintgen DS, Morrow M, Leitch AM, Hunt KK, McCall LM, Abati A, Cote R. Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer. JAMA. 2011 Jun 27;306(4):385-393.

Weaver DL, Ashikaga T, Krag DN, Skelly JM, Anderson SJ, Harlow SP, Julian TB, Mamounas EP, Wolmark N. Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med. 2011 Feb 3;364(5):412-421.