Disparities in the Surgical Management of the Axilla by Self-Identified Race in the Multicenter Neoadjuvant I-SPY2 Trial

Mandeep Kaur¹, Katrina Dimitroff², Judy C Boughey³, Laura J Esserman⁴, Christina Yau⁴, Julia Tchou⁵, Astrid Quirarte⁴, Marie Catherine Lee⁶, Marissa M Howard-McNatt⁷, Kayla Switalla⁴, Henry Kuerer⁸, Candice Sauder⁹, Lauren M Postlewait¹⁰, Cletus Arciero¹⁰, Roshni Rao¹¹, Anne Wallace¹², Chantal Reyna¹³, Kamran Ahmed¹⁴, Lily Gutnik¹⁵, Neil Taunk¹⁶, Jane Perlmutter¹⁷, Angela DeMichele¹⁸, Douglas Yee¹⁹, Nola M Hylton²⁰, W Fraser Symmans²¹, Hope S Rugo²², Rebecca A Shatsky²³, Claudine Isaacs²⁴, Sonali Rudra²⁵, Paula Pohlmann⁸, Cheryl Ewing⁴, Jasmine Wong⁴, Michael Alvarado⁴, Nora Jaskowiak²⁶, Nicolas Prionas²⁷, Mehra Golshan²⁸, Mara A Piltin²⁹, Olufunmilayo I Olopade³⁰, Rita A Mukhtar³¹

Affiliations

¹ School of Medicine, University of California San Francisco, San Francisco, CA, USA.
² University of California San Francisco, San Francisco, CA, USA.
³ Department of Surgery, Mayo Clinic, Rochester, MN, USA.
⁴ Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
⁵ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁶ Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL, USA.
⁷ Department of Surgical Oncology, Wake Forest, Winston-Salem, NC, USA.
⁸ Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA.
⁹ Department of Surgery, UC Davis Health Comprehensive Cancer Center, Sacramento, CA, USA.
¹⁰ Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
¹¹ Department of Surgery, Columbia University Medical Center, New York, NY, USA.
¹² Department of Surgery, University of California San Diego, San Diego, CA, USA.
¹³ Department of Surgery, Loyola University Medical Center, Chicago, IL, USA.
¹⁴ Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
¹⁵ Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
¹⁶ Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
¹⁷ Gemini Group, Ann Arbor, MI, USA.
¹⁸ Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
¹⁹ Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA.
²⁰ Department of Radiology, University of California, San Francisco, San Francisco, CA, USA.
²¹ Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²² Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
²³ Moores Cancer Center, University of California San Diego, La Jolla, San Diego, CA, USA.
²⁴ Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA.
²⁵ Department of Surgery, MedStar Georgetown University, Washington, DC, USA.
²⁶ Department of Surgery, University of Chicago, Chicago, IL, USA.
²⁷ Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA.
²⁸ Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
²⁹ Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
³⁰ Center for Clinical Cancer Genetics and Global Health, University of Chicago, Chicago, IL, USA.
³¹ Department of Surgery, University of California San Francisco, San Francisco, CA, USA. rita.mukhtar@ucsf.edu.

PMID: 40699532
PMCID: PMC12494629
DOI: 10.1245/s10434-025-17864-y

Multicenter Study

Disparities in the Surgical Management of the Axilla by Self-Identified Race in the Multicenter Neoadjuvant I-SPY2 Trial

Mandeep Kaur et al. Ann Surg Oncol. 2025 Oct.

. 2025 Oct;32(11):8211-8219.

doi: 10.1245/s10434-025-17864-y. Epub 2025 Jul 23.

Authors

Affiliations

¹ School of Medicine, University of California San Francisco, San Francisco, CA, USA.
² University of California San Francisco, San Francisco, CA, USA.
³ Department of Surgery, Mayo Clinic, Rochester, MN, USA.
⁴ Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
⁵ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁶ Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL, USA.
⁷ Department of Surgical Oncology, Wake Forest, Winston-Salem, NC, USA.
⁸ Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA.
⁹ Department of Surgery, UC Davis Health Comprehensive Cancer Center, Sacramento, CA, USA.
¹⁰ Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
¹¹ Department of Surgery, Columbia University Medical Center, New York, NY, USA.
¹² Department of Surgery, University of California San Diego, San Diego, CA, USA.
¹³ Department of Surgery, Loyola University Medical Center, Chicago, IL, USA.
¹⁴ Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
¹⁵ Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
¹⁶ Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
¹⁷ Gemini Group, Ann Arbor, MI, USA.
¹⁸ Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
¹⁹ Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA.
²⁰ Department of Radiology, University of California, San Francisco, San Francisco, CA, USA.
²¹ Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
²² Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
²³ Moores Cancer Center, University of California San Diego, La Jolla, San Diego, CA, USA.
²⁴ Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA.
²⁵ Department of Surgery, MedStar Georgetown University, Washington, DC, USA.
²⁶ Department of Surgery, University of Chicago, Chicago, IL, USA.
²⁷ Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA.
²⁸ Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
²⁹ Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
³⁰ Center for Clinical Cancer Genetics and Global Health, University of Chicago, Chicago, IL, USA.
³¹ Department of Surgery, University of California San Francisco, San Francisco, CA, USA. rita.mukhtar@ucsf.edu.

PMID: 40699532
PMCID: PMC12494629
DOI: 10.1245/s10434-025-17864-y

Abstract

Background: Neoadjuvant chemotherapy (NAC) may allow de-escalation of axillary surgery; yet treatment disparities persist. We aimed to assess race-based disparities in use of axillary lymph node surgery (ALND) among patients who achieve a nodal response in the context of a large, multicenter NAC trial.

Methods: We conducted a retrospective analysis of the I-SPY 2 trial. All patients received NAC, but type of surgery was not mandated. Multivariable logistic regression was used to predict odds ratio (OR) of undergoing ALND by race while adjusting for clinical and demographic confounders, including age, region, tumor receptor subtype, clinical and pathologic node status (cN and ypN +/-, respectively), and clinical and pathologic tumor size (cT and ypT, respectively).

Results: Among 1394 patients, 79.4% identified as White, 11.2% Black, and 9.4% Asian/other. More than half (52.5%) were cN+ at baseline, and 66.9% were ypN- after NAC, with no significant differences in nodal downstaging by race. Overall ALND rates were higher in Black patients (50.6%) compared to White (37.5%) and Asian/other (38.9%) patients (p = 0.007). Notably, among those who converted from cN+ to ypN-, Black patients underwent ALND more frequently (62%) than White (41.2%) and Asian/other (40%) patients (p = 0.021). In multivariable analysis, Black patients had 70% higher odds of undergoing ALND compared with White patients (OR 1.7, 95% confidence interval (CI) 1.09-2.66, p = 0.02).

Conclusions: Despite no differences in nodal downstaging, Black patients in I-SPY 2 were significantly more likely to undergo ALND. These disparities may stem from unmeasured patient, provider, or systemic factors affecting surgical planning.

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Conflict of interest statement

Disclosure: All other authors declare no competing interests.

References

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Disparities in the Surgical Management of the Axilla by Self-Identified Race in the Multicenter Neoadjuvant I-SPY2 Trial

Affiliations

Disparities in the Surgical Management of the Axilla by Self-Identified Race in the Multicenter Neoadjuvant I-SPY2 Trial

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical