In Reply We appreciate the opportunity to address the comments of Goyal et al regarding our study results.1 Although they unfortunately chose to characterize our sample as “predominately middle-aged surgeons…who are willing to complete a survey,” our study participants were in fact 376 surgeons treating patients drawn from population-based registries, and the survey response rate was substantial (77%). In this sample, which is likely to be representative of surgeons treating breast cancer in the United States in recent years, we were dismayed to observe that 179 (49%) would recommend axillary lymph node dissection (ALND) in the scenario of a patient with 1 macrometastasis in a sentinel node after breast-conserving surgery when ALND was not shown to yield benefit and was shown to increase lymphedema risk in the landmark ACOSOG Z0011 trial,2 which was published well before the time of our survey. The suggestion by Goyal et al that limited access to axillary radiotherapy may explain the reluctance to give up ALND seems highly unlikely given that patients in the ACOSOG Z0011 trial and our case scenarios had breast-conserving therapy, which requires whole-breast irradiation. It is not reasonable to assume that patients have access to breast radiotherapy but not axillary radiotherapy.
Morrow M, Jagsi R, Katz SJ. Undissected Axilla and Axillary Radiotherapy—In Reply. JAMA Oncol. Published online March 14, 20195(5):742–743. doi:10.1001/jamaoncol.2019.0050
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