Sentinel Lymph Node Positivity Rates for Breast Cancer and Melanoma: an Opportunity to Improve Quality and Enhance the NCCN Guidelines

There is significant hospital-level variation in the quality of cancer care delivered in the U.S. for breast cancer and melanoma.(10-13) It has been suggested that a hospital’s SLN positivity rate may be a quality indicator(14, 15), and when found to be lower than expected compared to other hospitals, it may be an indication of poor performance and offer an opportunity for targeted quality improvement. Some of the variability in SLN positivity rates for melanoma comes from hospital-to-hospital differences in patient and tumor characteristics as institutions have different practices regarding which melanoma patients undergo a SLNB. NCCN guidelines frequently suggest that SLNB be “considered” or “discussed,” so it is expected that providers have differences in how they recommend SLNB to patients.(1, 2) This could affect hospital SLN positivity rates, and must be considered in the statistical analyses of hospital SLN positivity rates. More importantly, predicted SLNB positivity rates could be used to develop an empiric decision aide to enhance the NCCN Guidelines and provide more objective information about when to offer a SLNB in borderline candidates. SPECIFIC AIM 1. To examine variability in adjusted sentinel lymph node positivity rates for hospitals in order to identify hospitals with lower rates than expected for breast cancer and melanoma. We hypothesize that some hospitals will have statistically and clinically significantly lower SLN positivity rates than expected after adjusting for patient and primary tumor factors; and provider and hospital characteristics are associated with lower SLN positivity rates. We also hypothesize that the patients treated at hospitals with low SLN positivity rates will have worse 5-year survival rates, after adjusting for differences in patient and tumor factors. SPECIFIC AIM 2.To use predicted patient SLN positivity rates to develop a decision aide to facilitate patient and clinician decision making regarding when to perform a sentinel lymph node biopsy for melanoma. We hypothesize that a decision tool can enhance the NCCN Guidelines by providing an empiric method to help decide when to perform a SLNB.