Effect on patients must be considered

EDITOR—Careful consideration needs to be given to the implications for breast cancer patients from the use of the unevaluated technique of sentinel node biopsy.1 Ideally, clinical trials to refine this technique should have been done before its introduction into routine clinical practice by enthusiastic surgeons. Training courses and conferences on this topic must be timed to avoid encouraging premature introduction and wasting resources.

The possibility that sentinel node biopsy would avoid clearance of the axilla, with its attendant problems, could be seductive to both surgeons and patients. The technique holds promise of clearer prognosis and swifter assessment with minimum invasiveness. What then might the drawbacks be for patients? Consideration of the best total outcome for the patient must always be the overriding objective.

It might be useful to draw a parallel between the introduction of mammographic screening, which resulted in closer scrutiny of breast tissue, and the use of sentinel node biopsy. Screening caused the label “breast cancer” to be applied to borderline cases so that many women with non-invasive conditions which would never cause them problems in their lifetime carried the “cancer” label with all its drawbacks, emotional and financial. By the same token, closer scrutiny of the sentinel node will cause an upstaging of the disease. Techniques such as step sections, immunostaining, and polymerase chain reaction (which can detect 1in 10000 cancer cells) “metastatic” is applied more readily, with enormous implications for the women given that label.

Foucar commented on the surprising docility of patients about the pathologist's monopoly on diagnostic terminology that links objective histopathological observations to clinical interventions.2 Classifications resulting from the use of sentinel …