Lymph Node Study Shakes Pillar of Breast Cancer Care

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Lymph Node Study Shakes Pillar of Breast Cancer Care

By DENISE GRADY

Published: February 8,

2011http://www.nytimes.com/2011/02/09/health/research/09breast.html?nl=todayshea\

dlines & emc=tha2

A new study finds that many women with early breast cancer do not need a painful

procedure that has long been routine: removal of cancerous lymph nodes from the

armpit.

Less Surgery for Breast Cancer?

Less Surgery for Breast Cancer?

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Breast Cancer

The discovery turns standard medical practice on its head. Surgeons have

been removing lymph nodes from under the arms of breast cancer patients

for 100 years, believing it would prolong women’s lives by keeping the cancer

from spreading or coming back.

Now, researchers report that for women who meet certain criteria — about

20 percent of patients, or 40,000 women a year in the United States —

taking out cancerous nodes has no advantage. It does not change the

treatment plan, improve survival or make the cancer less likely to

recur. And it can cause complications like infection and lymphedema, a chronic

swelling in the arm that ranges from mild to disabling.

Removing the cancerous lymph nodes proved unnecessary because the women in the

study had chemotherapy

and radiation, which probably wiped out any disease in the nodes, the

researchers said. Those treatments are now standard for women with

breast cancer in the lymph nodes, based on the realization that once the

disease reaches the nodes, it has the potential to spread to vital

organs and cannot be eliminated by surgery alone.

Experts say that the new findings, combined with similar ones from

earlier studies, should change medical practice for many patients. Some

centers have already acted on the new information. Memorial Sloan-Kettering

Cancer Center

in Manhattan changed its practice in September, because doctors knew

the study results before they were published. But more widespread change

may take time, experts say, because the belief in removing nodes is so

deeply ingrained.

“This is such a radical change in thought that it’s been hard for many

people to get their heads around it,†said Dr. Morrow, chief of

the breast service at Sloan-Kettering and an author of the study, which is being

published Wednesday in The Journal of the American Medical Association. The

National Cancer Institute paid for the study.

Doctors and patients alike find it easy to accept more cancer treatment

on the basis of a study, Dr. Morrow said, but get scared when the data

favor less treatment.

The new findings are part of a trend to move away from radical surgery for

breast cancer. Rates of mastectomy, removal of the whole breast, began declining

in the 1980s after studies found that for many patients, survival rates after

lumpectomy and radiation were just as good as those after mastectomy.

The trend reflects an evolving understanding of breast cancer. In

decades past, there was a belief that surgery could “get it all†—

eradicate the cancer before it could spread to organs and bones. But

research has found that breast cancer can begin to spread early, even

when tumors are small, leaving microscopic traces of the disease after surgery.

The modern approach is to cut out obvious tumors — because lumps big

enough to detect may be too dense for drugs and radiation to destroy —

and to use radiation and chemotherapy to wipe out microscopic disease in

other places.

But doctors have continued to think that even microscopic disease in the

lymph nodes should be cut out to improve the odds of survival. And

until recently, they counted cancerous lymph nodes to gauge the severity

of the disease and choose chemotherapy. But now the number is not so

often used to determine drug treatment, doctors say. What matters more

is whether the disease has reached any nodes at all. If any are

positive, the disease could become deadly. Chemotherapy is recommended,

and the drugs are the same, no matter how many nodes are involved.

The new results do not apply to all patients, only to women whose disease and

treatment meet the criteria in the study.

The tumors were early, at clinical stage T1 or T2, meaning less than two

inches across. Biopsies of one or two armpit nodes had found cancer,

but the nodes were not enlarged enough to be felt during an exam, and

the cancer had not spread anywhere else. The women had lumpectomies, and

most also had radiation to the entire breast, and chemotherapy or

hormone-blocking drugs, or both.

The study, at 115 medical centers, included 891 patients. Their median

age was in the mid-50s, and they were followed for a median of 6.3

years.

After the initial node biopsy,

the women were assigned at random to have 10 or more additional nodes

removed, or to leave the nodes alone. In 27 percent of the women who had

additional nodes removed, those nodes were cancerous. But over time,

the two groups had no difference in survival: more than 90 percent

survived at least five years. Recurrence rates in the armpit were also

similar, less than 1 percent. If breast cancer is going to recur under

the arm, it tends to do so early, so the follow-up period was long

enough, the researchers said.

One potential weakness in the study is that there was not complete

follow-up information on 166 women, about equal numbers from each group.

The researchers said that did not affect the results. A statistician

who was not part of the study said the missing information should have

been discussed further, but probably did not have an important impact.

It is not known whether the findings also apply to women who do not have

radiation and chemotherapy, or to those who have only part of the

breast irradiated. Nor is it known whether the findings could be applied

to other types of cancer.

The results mean that women like those in the study will still have to have at

least one lymph node

removed, to look for cancer and decide whether they will need more

treatment. But taking out just one or a few nodes should be enough.

Dr. E. Giuliano, the lead author of the study and the chief of surgical

oncology at the Wayne

Cancer Institute at St. ’s Health Center in Santa , Calif.,

said: “It shouldn’t come as a big surprise, but it will. It’s hard for

us as surgeons and medical oncologists and radiation oncologists to

accept that you don’t have to remove the nodes in the armpit.â€

Dr. Grant W. Carlson, a professor of surgery at the Winship Cancer Institute at

Emory University, and the author of an editorial accompanying the study, said

that by routinely taking out many nodes, “I have a feeling we’ve been doing

a lot of harm. "

But Dr. Carlson said that some of his colleagues, even after hearing the

new study results, still thought the nodes should be removed.

“The dogma is strong,†he said. “It’s a little frustrating.â€

Eventually, he said, genetic testing of breast tumors might be enough to

determine the need for treatment, and eliminate the need for many node

biopsies.

Two other breast surgeons not involved with the study said they would take it

seriously.

Dr. R. Port, the chief of breast surgery at Mount Sinai Medical Center in

Manhattan, said: “It’s a big deal in the world of breast cancer. It’s

definitely practice-changing.â€

Dr. Alison Estabrook, the chief of the comprehensive breast center at

St. Luke’s-Roosevelt hospital in New York said surgeons had long been

awaiting the results.

“In the past, surgeons thought our role was to get out all the cancer,â€

Dr. Estabrook said. “Now he’s saying we don’t really have to do that.â€

But both Dr. Estabrook and Dr. Port said they would still have to make

judgment calls during surgery and remove lymph nodes that looked or felt

suspicious.

The new research grew out of efforts in the 1990s to minimize lymph node

surgery in the armpit, called axillary dissection. Surgeons developed a

technique called sentinel node biopsy, in which they injected a dye

into the breast and then removed just one or a few nodes that the dye

reached first, on the theory that if the tumor

was spreading, cancer cells would show up in those nodes. If there was

no cancer, no more nodes were taken. But if there were cancer cells, the

surgeon would cut out more nodes.

Although the technique spared many women, many others with positive

nodes still had extensive cutting in the armpit, and suffered from side

effects.

“Women really dread the axillary dissection,†Dr. Giuliano said. “They

fear lymphedema. There’s numbness, shoulder pain, and some have limitation of

motion. There are a fair number of serious complications. Women know it.â€

After armpit surgery, 20 percent to 30 percent of women develop

lymphedema, Dr. Port said, and radiation may increase the rate to 40

percent to 50 percent. Physical therapy can help, but there is no cure.

The complications — and the fact that there was no proof that removing

the nodes prolonged survival — inspired Dr. Giuliano to compare women

with and without axillary dissection. Some doctors objected. They were

so sure cancerous nodes had to come out that they said the study was

unethical and would endanger women.

“Some prominent institutions wouldn’t even take part in it,†Dr.

Giuliano said, though he declined to name them. “They’re very supportive

now. We don’t want to hurt their feelings. They’ve seen the light.â€

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