• Tsai-Wei Huang, Ken N Kuo, Kee-Hsin Chen, Chiehfeng Chen, Wen-Hsuan Hou, Wei-Hwa Lee, Tsu-Yi Chao, Jo-Ting Tsai, Chih-Ming Su, Ming-Te Huang, and Ka-Wai Tam.
• Department of Nursing, College of Medicine and Nursing, HungKuang University, Taichung City, Taiwan.
• Int J Surg. 2016 Oct 1; 34: 73-80.

BackgroundIn 2014, the American Society of Clinical Oncology published an updated clinical practice guideline on axillary lymph node dissection (ALND) for early-stage breast cancer patients. However, these recommendations have been challenged because they were based on data from only one randomized controlled trial (RCT). We evaluated the rationale of these recommendations by systematically reviewing RCTs using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system.MethodsWe searched articles in the PubMed, EMBASE, CINAHL, Scopus, and Cochrane databases. The primary endpoints were overall survival (OS) and disease-free survival (DFS). The secondary endpoints were recurrence rate and surgical complications of axillary dissection. The quality of evidence was assessed using the GRADE profiler.ResultsFive eligible studies were retrieved and analyzed. We divided sentinel lymph node (SLN) metastasis into two categories: SLN micrometastasis and SLN macrometastasis. In patients with 1 or 2 SLN micrometastasis, no significant difference was observed in OS, DFS, or recurrence rate between the ALND and non-ALND groups. For patients with 1 or 2 SLN marcometastasis, only one trial with a moderate risk of bias was included, and non-ALND was the preferred management overall. However, ALND might be appropriate for patients who placed a greater emphasis on longer-term survival at any cost.ConclusionWe recommend non-ALND management for early breast cancer patients with 1 or 2 SLN micrometastasis or macrometastasis on the basis of a systematic review of the current evidence conducted using the GRADE system. However, the optimal practice of evidence-based medicine should incorporate patient preferences, particularly when evidence is limited.Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

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