Study: Lymph node removal not always needed for breast cancer patients

A study published today in the Journal of the American Medical Association finds that as many as 20 percent of women with breast cancer may be able to skip the painful surgery to remove infected lymph nodes under their arms, avoiding complications like lymphedema without harming their health.

The news is "very exciting," says Dr. Mehra Golshan, director of breast surgery at the Dana-Farber Cancer Institute in Boston. "It is practice-changing in many respects."

Until just a few decades ago, a breast cancer patient's primary option was a radical mastectomy, the removal of the entire breast and surrounding tissue, including the lymph nodes in the armpit. In the 1980s, studies showed that lumpectomies, which targeted just the tumors and spared much of the breast, worked well for many patients when coupled with radiation therapy.

Being able to retain the lymph nodes "is really a move toward less radical surgery" for breast cancer patients, study author Dr. Armando Giuliano, cancer surgery chief at the John Wayne Cancer Institute in Santa Monica, California, told the Associated Press.

During a lumpectomy, a few of the guardian or sentinel lymph nodes are removed and tested for cancer, explained Dr. Golshan, who was not a part of the study. Until now, if cancer was detected in even a single sentinel node, all of the axillary lymph nodes (the ones inside the arm pit) were removed. The idea was to stop the spread or recurrence of cancer, but the procedure often caused long-term complications, including numbness, loss of mobility, infection, and lymphedema-a chronic, incurable swelling of the arm.

The JAMA study involved about 900 women and found that, a little more than six years after treatment, overall survival rates were virtually identical for women who had retained their axillary lymph nodes (92.5 percent) and those who had theirs removed (91.8 percent). The disease-free survival rate was 83.9 percent for those who did not have their lymph nodes removed, and 82.2 percent for those who did. So, for breast cancer patients who meet the same criteria as those in the study, removing all of the axillary lymph nodes is not necessary-and keeping them could make for a better quality of life.

Women who undergo lumpectomies are normally also treated with chemotherapy or hormone-blocking drugs and radiation that targets the whole breast and part of the armpit. The study shows that this additional treatment may be enough to destroy cancer cells in any remaining lymph nodes. The study did not consider outcomes for women who do not have radiation or chemo, or for those who only have radiation applied to part of their breast; it is also not known whether the findings would be the same with other types of cancer. The median age of patients in the study was the mid-50s.

If you've recently been diagnosed with breast cancer, you and your medical team may be wondering how the JAMA study affects you. We turned to Dr. Golshan of Dana-Farber Cancer Institute for answers to some of the big questions:

How does a woman (and her doctor) know if she meets the study's criteria and decide whether forgoing lymph node removal is an option?

Women with early stage (T1 or T2) breast cancer, with tumors less than 5 centimeters (2 inches) in size, with cancer detected in just one or two sentinel lymph nodes, are the best candidates for avoiding the removal of additional the axillary lymph nodes, says Dr. Golshan of Dana-Farber. According to the study, about 20 percent of breast cancer patients-as many as 40,000 women per year in the United States-could qualify.

Are there any patients who should have their axillary lymph nodes removed anyway?

Women who chose or needed a mastectomy would still need to have their axillary lymph nodes removed, Dr. Golshan says, as would anyone whose cancer has already "burst through lymph nodes" or whose tumors, when removed, do not have a margin of clear, cancer-free breast tissue around them. "It's a very personal decision, just like breast conservation therapy and mastectomy," Dr. Golshan points out. "Some patients will decide that they should have it."

What are the benefits to avoiding lymph node removal?

Dr. Golshan notes that if the patient is undergoing a lumpectomy, the breast conservation and post-op treatment stay the same whether she has the axillary nodes removed or not. But if the axillary nodes are not removed, recovery is quicker, infection rates are lower, and while the patient still could develop lymphedema, the risk is much lower: 2 percent to 5 percent, as opposed to as high as 25 percent. "The lymphedema rates are not zero," Dr. Golshan says. "It's just a lot less." You also regain full range of motion much more quickly after surgery and, unlike patients who have had their axillary lymph nodes removed, you can still use the arm for blood pressure readings and blood draws. Lymphedema has no cure, though physical therapy can help in some patients.

What could the study mean for breast cancer treatment in general?

Dr. Golshan cautions that there are still some concerns. Many cancers were hormone-sensitive, and those types of cancers can take more than a decade to recur, but the study only followed women for a little more than six years. "We don't know if things may change a little bit farther down the road," he pointed out.

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