Disparities in receipt of lymph node assessment among early stage female breast cancer patients

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Accurate staging of breast cancer requires assessment of axillary lymph node involvement. We evaluated factors associated with receipt of lymph node assessment among women with early stage breast cancer using data from the National Cancer Database (NCDB), a hospital-based registry jointly sponsored by the American Cancer Society and American College of Surgeons. Records for all women diagnosed with early stage breast cancer (T1a, T1b, T1c, and T2N0) from 2003-2005 were extracted from the NCDB. Analyses explored the impact of patient race/ethnicity, insurance status, and age on receipt of any axillary lymph node procedure (axillary lymph node dissection or sentinel lymph node biopsy) while controlling for other sociodemographic and clinical factors using multivariate logistic regression. A total of 196,732 women met the study inclusion criteria; 11% did not receive any axillary lymph node assessment. Compared to White patients, Black patients had greater likelihood (odds ratio [OR] 1.10, p<0.001) of receiving no axillary lymph node assessments; there were no significant differences for Hispanic or other non-White patients. Individuals who were uninsured had greater likelihood (OR 1.24, p<0.0005) of no axillary lymph node assessment compared to those with private insurance; a similar increase in the likelihood of no axillary lymph node assessment was observed for Medicare patients younger than age 65 (OR 1.29, p<0.0001), while Medicaid patients and Medicare patients 65 and older were not significantly different from those with private insurance. Patients who resided in zip codes with the lowest education levels were significantly more likely to receive no lymph node assessment compared to those from areas with the highest education levels (OR 1.13, p=0.0001). The greatest disparities were observed by age group; compared to the youngest quartile of patients (age < 51), those 62 to 72 were 1.1 times a likely to receive no axillary lymph assessment (p<0.01), while patients in the oldest quartile (age 73 and older) were more than three times as likely (OR 3.30, p<0.0001) not to receive any assessment. These results indicate that significant disparities exist in receipt of axillary lymph node assessments among women with early stage breast cancer. While guidelines indicate that axillary lymph node assessment may be considered optional in certain patient groups, it remains a key component in determining stage, and thereby both prognosis and appropriate treatment options. Disparity in receipt of this procedure among underserved populations is therefore a concern and requires further study.