Sentinel Lymph Node Biopsy for Early Breast Cancer: A Prospective National Evaluation of Costs and Impact on Pain and Quality of Life Compared with Complete Lymphadenectomy.
Authors: Classe J. 
Published: December 2010

Abstract
Sentinel Lymph Node Biopsy (SLNB) is an alternative to Axillary Lymph Node Dissection (ALND) for early breast cancer. Compared with axillary lymphadenectomy, SLNB using the combined method, with blue staining and isotope, and specific pathologic techniques with serial sectioning and immunohistochemistry appears to be an expensive procedure. The main objective of our study was to compare the cost of the SLNB with that of ALND. The secondary objectives were to compare morbidity, impact on quality of life and pain between SLNB and ALND.Methods: A prospective, observational, comparative and cost-consequences study was carried out with 16 participating French comprehensive cancer centers. Inclusion criteria were invasive breast cancer, tumour size &lt;2cm, surgical conservative treatment, no clinical axillary suspicious nodes. For surgical axillary evaluation, patients of the SLNB group underwent SLNB with the combined method and ALND only in the case of detection failure or sentinel node involvement, and patients in the ALND group underwent a systematic level I-II ALND. The choice between SLNB and systematic ALND was left to the surgical team. Different viewpoints (hospital, Health Insurance, society) were taken into consideration for the economic evaluation using a microcosting methodology. Consequences on quality of life (QLQ-C30), morbidity (QLQ-Br23) and pain (EVA) were assessed at various times (before surgery, at one, three, six months, and until one year thereafter).Results: From September 2005 to December 2006, 957 patients were included (817 in the SLNB group and 140 in the ALND group). The total costs (treatment and complications-related costs at one month) did not differ between the two groups (€3,776 for SLNB vs €3,868 for ALND, p=0.62).The costs associated with the subgroup of patients who had SLNB with intra-operative pathologic examination and without ALND were lower than those observed for patients in the ALND group (€2,971 vs. €3,337, p=0.002). The intra-operative examination contributed significantly with 16% (132/817) of SLNB patients who underwent a second surgical procedure for ALND.Quality of life indicators favored the SLNB technique. Two months after the surgery, the patients from the SLNB group recovered their initial quality of life whereas patients from the ALND group had to wait 8 months to do so. Symptoms related to arm and armpit pain were significantly less at one year for the SLNB group than for the ALND group (p=0.01). The negative effect on pain or quality of life, of a secondary ALND after a SLNB compared to ALND at the time of SLNB, was not established.Conclusion: Economic Health Technology Assessment shows that SLNB is a cost-effective procedure. Considering the group of patients with a low risk of pathological lymph node involvement (with a small tumor size and no clinical axillary involvement), the ASLN procedure is less expensive than systematic lymphadenectomy.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1021.