Study rebuts widely-held beliefs about cancer surgery.
HACKENSACK, N.J. — Many women with breast cancer will no longer face a potentially devastating side effect of their cancer surgery, as the conclusions of a newly published study about the need to remove underarm lymph nodes are taken to heart by breast surgeons.
“This was a celebratory day for me,” said Dr. Laura Klein, medical director of The Valley Hospital’s breast center. “It’s practice-changing. I personally will no longer be performing axillary node dissections” on women who match the study criteria.
At Holy Name Medical Center in Teaneck, N.J., Dr. Erika Brinkmann, director of the breast center, said she would act on the study results “immediately.”
“It will influence not only my practice but everyone’s practice,” said Dr. David Pearlstone, chief of breast surgery at Hackensack University Medical Center. The medical center’s breast-cancer team, including surgeons, radiologists, medical oncologists and nurse practitioners, will discuss the findings at its next weekly meeting on Wednesday, he said.
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The study, published Wednesday in the Journal of the American Medical Association, found that women who underwent lumpectomies for tumors of less than 2 inches and whose lymph nodes did not have obvious signs of disease, showed no difference in survival if many lymph nodes were removed or if only their sentinel nodes were removed.
Surgeons will still remove one to three sentinel nodes, the first nodes that drain lymphatic fluid from the breast, to see if the cancer is spreading beyond the breast. Finding cancer in those nodes indicates that disease cells have migrated and could cause metastases elsewhere. Such patients almost always are treated with chemotherapy.
But until now, a finding of cancer in the sentinel node had led surgeons to remove more nodes — either at the same time as the lumpectomy or with a return to the operating room later — to try to make sure that no cancer cells remained in the body. The study showed that this makes no difference in terms of cancer recurrence in the same breast, disease-free survival, or overall survival.
With or without the additional surgery, called an axillary node dissection, more than 90 percent of the women survived for five years. With or without it, the chance of a cancer recurrence in the same breast was less than 4 percent.
That conclusion upends one of the most closely held beliefs about cancer surgery, that it is best to “get it all out.”
“As cancer surgeons, it’s anathema to us to know we leave cancer behind,” Pearlstone said. “But here’s a study that says, hey, it doesn’t matter.”
“We always have felt that the role of the surgeon is to cut it all out,” Brinkmann said. “It’s very hard not to fall into that hole. But we have to look at the data and the studies that have been done. This will be the standard of care now” for women who match the study criteria.
The findings further the trend toward less-invasive breast cancer treatment. In recent decades, lumpectomies, when combined with radiation treatment, have been shown to be as effective as mastectomies for many women. And sentinel-node biopsies have replaced wholesale initial excision of lymph nodes.
Knowing how many additional lymph nodes contain cancer does not change decisions about whether to use chemotherapy and what type of chemotherapy to use, said the study, by Dr. Armando Giuliano of the John Wayne Cancer Institute in California and others.
Oncologists increasingly base their chemotherapy treatment on the specific characteristics of the patient’s tumor, including the cells receptivity to estrogen and progesterone and their molecular composition.
The study is significant because for many women, the worst side effects of breast-cancer surgery result not from the breast incision, but the lymph node removal. “A few women suffer medical problems from having a sentinel node removed,” Pearlstone said. “But many, many, many suffer medical problems from having a whole lot” of nodes removed.
“There’s a lot going on in that area,” under the arm, said Carolyn Monroe, a nurse-practitioner in the surgical breast practice at Hackensack, N.J. “It’s the junction from your arm to your torso and shoulder and neck.” Many muscles and nerves join and intersect.
Side effects may include pain, tingling, numbness, weakness, tightening or a cord-like feeling that can extend down the arm, and lymphedema, a permanent swelling that can limit motion and for which there is no cure.
Recovery after surgery is expected to be easier, too, because women will not require underarm drains for weeks if they have not had multiple lymph nodes removed.