Lymph Node Surgery for Breast Cancer: More Harm Than Good?
When you hear the words “You have cancer,” your life changes – instantly.
All of a sudden, you’ve crossed a line: the “cancer divide.” You’ve joined the hundreds of thousands of Americans who are battling this wretched disease.
Some of us live; some of us die. And all of us are marked by the experience for life.
Cancer comes with a centuries-old, ugly reputation. For hundreds of years, the chief weapon against solid-tumor cancers has been the knife.
Isolate the tumor; cut it out. Find out where it’s spread; do some more cutting. Surgically obliterate all traces of cancer, and only then move on to adjuvant therapy: chemo, radiation, drugs.
Surgery as the first bastion of defense for a particular group of cancer patients took a huge hit this week, however, when the Journal of the American Medical Association reported results of a study involving breast cancer survivors.
It appears that surgically removing all traces of cancer might not make the difference in recurrence and survival rates doctors have always believed it does.
Here’s the story. Back in 1999 researchers enrolled nearly 900 women from 115 sites around the country in a clinical study, randomizing them into two groups. The criteria specified women with tumors under 2cm in size; no palpable lymph nodes; and no spread of the cancer to other parts of the body.
All of the women had a sentinel node biopsy (removal of one or two lymph nodes); breast conservation surgery (lumpectomy), and whole-breast radiation. All of the women were identified as having either one or two cancerous lymph nodes.
In the past, just one positive node would have meant removal of most, if not all of the remaining lymph nodes under the arm. Doctors believed that if the cancer had spread outside the breast, there was every chance it had gone beyond a single node; best to simply remove them all.
But here’s what the study sought to prove: contrary to long-held beliefs, removing some or all of the remaining lymph nodes doesn’t improve survival, nor reduce recurrence rates.
Half the women in the trial had at least 10 additional nodes removed. The other half, none. And at a median follow-up of 6.3 years, recurrence and survival rates were virtually identical for both groups.
How could this be? Researchers conclude that radiation and/or chemo and/or long-term hormone therapy are just as effective as surgery at fighting cancer that’s spread to the lymph nodes.
So why is this news being received with sadness and frustration by breast cancer survivors all over the country?
Because it appears that for over 100 years, ever since surgeons began regularly removing underarm lymph nodes to fight cancer, women have been subjected to more surgery than they needed. Surgery which often resulted in serious complications, including shoulder issues; infections; and lymphedema, a potentially crippling arm condition that can occur immediately after surgery, or up to decades later.
For many women, especially those who’ve had numerous nodes removed, fear of lymphedema is an emotional burden that lasts a lifetime.
And, for those dealing with this incurable condition, the treatment is tedious and expensive. Bulky arm wraps, regular trips to a therapist for treatment, and a full-time elastic arm sleeve and glove are just some of what lymphedema sufferers deal with.
So, hearing that perhaps underarm surgery wasn’t necessary after all is disappointing – to say the least – to those women who’ve had it, and are dealing with its lifelong after-effects.
“Lymph Node Study Shakes Pillar of Breast Cancer Care,” cried a New York Times headline on Tuesday. But will the results of this new study actually change the way surgeons and oncologists operate?
Maybe. The Times reports that Gary Lyman of the American Society of Clinical Oncology (ASCO), a non-profit group of nearly 30,000 oncology practitioners, said “the findings will prompt the group to revise its recommendations for breast cancer patients.”
It’s estimated that going forward, 60% to 70% of breast cancer patients with cancer in their lymph nodes – nearly 50,000 American women, every year – may be encouraged to opt out of further surgery, and its potential pain and suffering.
The radical mastectomies of 30 years ago have gradually given way to much simpler, less disfiguring mastectomies. And in many cases, breast conservation surgery has proven just as effective as mastectomy, allowing more and more women to keep their breasts.
Less aggressive lymph node surgery is another step on the path of evolving cancer treatment. And it makes one wonder: how long will it be until targeted therapies and genomics make cancer surgery obsolete, a barbaric remnant of medicine’s distant past?