Breast Cancer ChoicesTM  
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Scrutinizing the evidence for breast
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    The biopsy on my tumor was positive for cancer. My doctor has
    recommended a sentinel lymph node biopsy (SLNB) or sentinel lymph
    node dissection (SNLD) to see if the cancer has spread.  How invasive
    is this procedure?

    According to the veterans in the online discussion group, whether to have
    the lymph nodes tested was one of the most important, life-altering decisions
    they made. One of the major reasons for setting up the Breast Cancer Choices
    website was the suffering of members who had some or all of their axillary
    nodes removed.

    They wanted other women warned that they could be handicapped for life
    by nerve-severing, lymphedema, or phlebitis. The lymph node dissection
    procedure has resulted in some women's inability to pick up children, trouble
    carrying groceries, arm weakness and swelling as well as numbness and limited
    range of motion. At least two of our members had nerves severed.

    LYMPH NODE DISABILITIES ARE NOT CURABLE. The lymph node dissection is done
    as a diagnostic, not a therapeutic procedure. However, many surgeons still believe
    removing cancerous nodes is therapeutic despite the evidence.

    Even though the sentinel lymph node biopsy is a more limited procedure than a full
    axillary dissection of the nodes, you may nonetheless be required in advance to
    grant your surgeon permission to remove other nodes if the sentinel node is
    cancerous. The complication rate for sentinel node biopsy, including reactions to the
    radioactive dye, must also be considered. See additional articles if you are
    considering this procedure.

    The decision to give permission to dissect the lymph nodes is a major one.  Ask your
    surgeon why you need your lymph nodes tested.  The answer will probably be one of
    the following: "It's standard procedure, "We need to stage you." "If there is cancer in
    the nodes we will remove it."

    All of the above statements are true. Most patients get this procedure done because
    it is the standard package and they don't question whether it will improve their odds
    of survival., But staging via the lymph node evaluation may have no value to the
    patient if she is going to pursue conventional or alternative treatments aggressively
    anyway.

    Are there any safety issues with a sentinel lymph node biopsy?

    Dr. Robert Rosser recommends that the SLND should be done without massage or
    any other attempt to hasten the flow of lymph to the lymph nodes. Dr. Rosser
    contends that occult micrometastases (CK-IHC-positive micrometastases) in the
    sentinel lymph nodes may be the result of the sentinel node procedure itself.

    "Medical practioners routinely massage the breast, sometimes with heat, to increase
    the flow of lymph, radiosotope, and blue dye to the axilla.  Scrub nurses massage the
    breast to prepare the skin for the surgical skin incisions.  Surgeons grasp breast
    tumors with clamps and forceps to retract them while completing the tumor's
    excision. It should not be surprising  that cellular fragments of less cohesive tumors
    are disrupted and are caught in the flow of lymph.  The danger to the patient comes
    from those traumets that do not get trapped in the sentinel lymph node but enter the
    systemic circulation." (See "Safety of Sentinel Lymph Node Dissection and
    Signficance of Cytokeratin Micrometastases" on the Robert Rosser, MD page.)

    Dr. Rosser recommends that the SLND should be done without massage or any other
    attempt to hasten the flow of lymph to the lymph  nodes.

    But what if the cancer has spread to the lymph nodes? Won't removing them
    improve my survival chances? That seems like common sense.

    Yes, it does seem like common sense that the removal of cancerous lymph nodes
    would improve the survival rate,  but the evidence seems to show a different role
    for the lymph nodes than was expected. That evidence hasn't yet impacted current
    surgical practice.

    The Management of Regional Lymph Nodes in Cancer  
    D.B. Pharis; J.A. Zitelli
    Br J Dermatol 149(5):919-925, 2003. © 2003 Blackwell Publishing  [excerpts]

    Management of the regional lymph nodes (RLNs) in potentially metastatic cancer is fraught with
    controversies and misunderstandings. Early surgical oncologists observed many times that the
    RLNs were enlarged in advanced cancers before distant disease appeared, leading to the theory
    that the RLNs served as mechanical barriers temporarily preventing systemic dissemination of
    tumour. Based on this theory, surgeons removed these enlarged lymph nodes along with the
    primary tumour, an approach known as therapeutic lymph node dissection (TLND), in an attempt
    at surgical cure of locally advanced disease. Unacceptable cure rates, believed to be a result of
    unresected microscopic disease, led to the removal of clinically normal RLNs, a procedure
    known as elective lymph node dissection (ELND), in an effort to remove these nonpalpable
    tumour deposits. By the early twentieth century, routine dissections of the regional lymphatics in
    an effort to remove all microscopic disease had become the dogma of surgical oncology based
    exclusively on observation and theory rather than sound scientific evidence. This barrier theory
    of lymph node biology continues to influence the management of the RLNs in cancer surgery
    today....[excerpt]

    The theoretical benefit of ELND seemed unassailable when considered in the context of the
    belief that the RLNs served as physical barriers to tumour dissemination. During a time when
    little else could be offered to cancer patients, this seemingly rational theory and the chance of a
    surgical cure for this dreaded disease captured the attention of surgeons around the world.
    Numerous retrospective and single institutional studies were published that supported the
    widespread use of ELND in nearly all forms of cancer with the potential for nodal metastasis
    including cancer of the breast, uterus, cervix, vulva, prostate, head and neck, penis and, of
    course, melanoma.[6-14] Advocates of ELND used the results of these uncontrolled studies to
    validate the theory that the RLNs were in fact barriers to systemic tumour dissemination.
    Consequently, the role of ELND in cancer surgery remained unchallenged in surgical oncology
    until late in the twentieth century.

    A turning point in this story began in 1960 when Bernard Fisher, then the director of the National
    Surgical Adjuvant Breast and Bowel Program, began an ambitious study that was to be the first
    randomized controlled trial (RCT) investigating the value of the ELND in breast cancer
    patients.[15] To the surprise of most, Fisher's study of 1700 patients failed to reveal any
    statistically significant survival advantage for patients undergoing ELND. Although the lymph
    node dissection group experienced fewer recurrences in the treated lymph node basin, this
    improvement in local control did not translate to a benefit in overall survival. In fact, when these
    patients did have recurrences, these were more likely to be distant disease. Since Fisher's
    landmark study, five RCTs evaluating ELND in breast cancer patients have failed to reveal a
    statistically significant survival advantage for patients treated with ELND.[16] The lack of
    evidence supporting the value of ELND for breast cancer patients in these five trials raised
    significant questions regarding the dogmatic but unproven traditional approach to surgical
    management in patients with cancer.
    ------------------------------------------------------------------
    For more complete references and more studies see Medical Articles on Lymph Node
    Removal

    What about the risk of lymphedema after node surgery?

    The risk of lympedema can depend on how many nodes were taken or if you have
    radiation after surgery. Lymphedema can develop immediately or occur years later.  A
    2003 study showed that there is a significantly lower rate of lymphedema in patients
    who have had SLND than full axillary dissection. (See Golshan, et al., Am Surg, [2003],
    in the Medical Articles Lymph page.)

    Lymph node surgery is so fraught with complications that even the American Cancer
    Society publishes an extensive list of activities patients should avoid
    for the rest of their lives. See below:

    How To Prevent and Control Lymphedema

    Although there are no scientific studies to show that people can prevent lymphedema, most experts
    recommend following these basic guidelines, which may lower your risk of developing lymphedema
    or delay its onset:

    Avoid Infections, Burns and Injuries. Try to avoid infections, burns, or injuries to the affected area.
    Your body responds to these by making extra fluid. Burns and injuries canal so lead to infections.
    Removal of or damage to lymph nodes and vessels makes it more difficult to transport this extra fluid,
    and this can trigger lymphedema.

    Keep the affected limb clean. Careful skin care may reduce the risk of lymphedema by helping you
    to avoid infections. Dry creases between your toes after bathing. Keep your hands, feet, and cuticles
    soft and moist by regularly applying moisturizing lotion or cream. Push cuticles back with a cuticle
    stick rather than cutting them with scissors. Clean and protect any openings in the skin caused by
    cuts, abrasions,insect bites, hangnails or torn cuticles by washing with soap and water. Use an over-
    the-counter antibacterial cream on any opening  once they are cleaned, and then cover with a
    clean bandage. For burns, apply a cold pack or cold water for 15 minutes, then wash with
    soap and water and apply a clean, dry dressing. Watch for early signs of infection: rash, red blotches,
    swelling,increased heat, tenderness, or fever.

    Call your doctor right away if you develop an infection. Use an electric shaver for removing underarm
    and leg hair; these maybe less likely to cut or break the skin than straight razors or hair removal
    creams. If necessary, use an insect repellent when outdoors to avoid bug bites. If a bee stings you in
    the affected limb, clean and elevate the limb,apply ice, and contact your doctor if it becomes
    infected. Avoid activities that irritate or chap the skin. Protect your limb from sunburn. Use sunscreen
    that is labeled SPF15 or higher and try to stay out of the sun during the hottest part of the day. Avoid
    oil splash burns from frying and steam burns from microwaved foods or boiling liquids. Your affected
    limb may not detect temperatures as well as it did in the past. Test bath water temperatures with an
    unaffected limb. Avoid excessive heat, such as from hot tubs and saunas, since heat can increase
    fluid build-up. Copyright American Cancer Society, Inc.

    Researchers at Memorial Sloan Kettering found the lymphedema rate was 49% by
    the time patients, who had had full axillary dissection, reached the 20 year mark.

    Cancer. 2001 Sep 15;92(6):1368-77.
    Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis.
    Petrek JA, Senie RT, Peters M, Rosen PP.
    Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York

    BACKGROUND: To the authors' knowledge, there are no long-term cohort studies of lymphedema,
    despite the substantial morbidity of arm swelling. The goal of this study was to identify prevalence
    of breast carcinoma-related lymphedema, time of onset, and associated predictive factors.
    METHODS:A cohort of 923women consecutively treated with mastectomy and complete axillary
    dissection at our center between 1976 and 1978 was observed intensively for 20 years. Two
    hundred sixty-three study subjects (28.5%) who were alive and recurrence free constituted the
    cohort for the current study. A subset of 52 women (20% of study population) with contralateral
    mastectomy was analyzed separately. Subjects reported circumferential arm measurements
    taken using a validated instrument.
    In addition to providing analysis of clinical and treatment variables, this study is the first to the
    authors' knowledge to analyze possible etiologic factors in the posttreatment years, such as
    occupation, general physical activity, and sports/leisure activities. Univariate and multivariate
    analytic methods were used.

    RESULTS: At 20 years after treatment, 49% (128 of 263) reported the sensation of lymphedema.
    Arm swelling measurements were severe (> or = 2.0 in [5.08 cm]; patients reported measurement
    in inches) for 13% (33 of 263 women). Seventy-seven percent (98 of 128) noted onset within 3 years
    after theoperation; the remaining percentage developed arm swelling at a rate of almost 1% per
    year. Of the 15 potential predictive factors analyzed, only 2 were statistically significantly
    associated with lymphedema: arm infection/injury and weight gain since operation (P < 0.001 and P
    = 0.02, respectively). CONCLUSIONS: This defined cohort, treated by axillary dissection 20 years
    ago, documents the high prevalence of lymphedema and its time course. Two significantly
    associated factors, both potentially controllable, are identified. The current study provides further
    support for treatments that limit lymph node dissection. The authors are prospectively evaluating
    patients undergoing sentinel lymph node biopsy. Copyright 2001 American Cancer Society.
    -----------------------------------------------------------------------------------------
    Can factors from the tumor biology --from the pathology report-- yield sufficient
    information to allow me to avoid axillary lymph node dissection?

    The Parmigiani study, cited below, suggests especially with respect to breast cancer patients who are
    considering undergoing  conventional treatments, that it may not be beneficial for those with early
    stage breast cancer who are ER negative to have axillary node dissection. The rationale for this
    suggestion is that the standard of care recommends chemotherapy whether or not cancer has spread
    to the nodes.  Women with early stage breast cancer who are ER positive may be the only ones who
    might benefit from axillary node dissection, since they may not require any treatment. Considering the
    axillary node procedure's potentially negative impact on the patient's quality of life, Parmigiani, et al., call
    for a reevaluation of this procedure, but surgeons have been slow to question what they have done
    routinely for so many years.

    J Clin Oncol. 1999 May;17(5):1465-73.
    Is axillary lymph node dissection indicated for early-stage breast cancer? A decision analysis.
    Parmigiani G, Berry DA, Winer EP, Tebaldi C, Iglehart JD, Prosnitz LR.
    Institute of Statistics and Decision Sciences and Center for Clinical Health Policy Research, Duke
    University, Durham, NC.

    PURPOSE: Axillary lymph node dissection (ALND) has been a standard procedure in the
    management of breast cancer. In a patient with a clinically negative axilla, ALND is performed
    primarily for staging purposes, to guide adjuvant treatment. Recently, the routine use of ALND has
    been questioned because the results of the procedure may not change the choice of adjuvant
    systemic therapy and/or the survival benefit of a change in adjuvant therapy would be small. We
    constructed a decision model to quantify the benefits of ALND for patients eligible for
    breast-conserving therapy. METHODS: Patients were grouped by age, tumor size, and
    estrogen receptor (ER) status. The model uses the Oxford overviews and three combined Cancer
    and Leukemia Group B studies. We assumed that patients who did not undergo ALND received
    axillar yradiation therapy and that the two procedures are equally effective. All chemotherapy
    combinations were assumed to be equally efficacious. RESULTS: The largest benefits from ALND
    are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant
    chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-negative women,
    almost all of whom would receive adjuvant chemotherapy. When adjusted for quality of life (QOL),
    ALND may have an overall negative impact. In general, the benefits of ALND increase with the
    expected severity of adjuvant therapy on QOL.
    CONCLUSION:
    Our model quantifies the benefits of ALND and assists decision making by patients and
    physicians. The results suggest that the routine use of ALND in breast cancer patients should be
    reassessed and may not be necessary in many patients.
    ------------------------------------------------------------------------------------------------
    In a study sponsored by the American Cancer Society, Viale et al. agreed with
    Parmigiani in their Feb 2005 conclusions, claiming tumor size and vascular invasion
    around the tumor were the most reliable predictors of sentinel node spread.









.
What is the
procedure most
regretted by breast
cancer patients?
Lymph Node
Removal

Link to medical
articles on lymph
node surgery
Can factors from
the tumor biology
(pathology report )
yield sufficient
yield sufficient
allow me to avoid
information to
axillary lymph node
dissection?

*** News Update ***
NY Times Feb 8, 2011

Lymph Node Study
Shakes Pillar of
Cancer Care
Read Article

JUNE 2010
NY TIMES
Read Article

Lymph Node
Dissection Provides
No Benefit to
Lumpectomy Patients

Some 82.2 percent of
the women who had the
dissection were alive
and disease free
compared with 83.8
percent of those who
did not. Cancer
recurred in the breast
or nearby in 4.3
percent of those who
had the operation and
3.4 percent in those
who did not.

Patients had more
distant recurrences with
axillary dissection.

excerpt from full text

To the surprise of most,
Fisher's study of 1700
patients failed to reveal any
statistically significant
survival advantage for
patients undergoing ELND.
Although the lymph node
dissection group
experienced fewer
recurrences in the treated
lymph node basin, this
improvement in local control
did not translate to a
benefit in overall survival.
In
fact, when these patients
did have recurrences,
these were more likely to be
distant disease
. Since
Fisher's landmark study,
five RCTs evaluating ELND
in breast cancer patients
have failed to reveal a
statistically significant
survival advantage for
patients treated with
ELND.[16] The lack of
evidence supporting the
value of ELND for breast
cancer patients in these
five trials raised significant
questions regarding the
dogmatic but unproven
traditional approach to
surgical management in
patients with cancer.













Lymphedema patient
    These statements have not been evaluated by the U.S. Food & Drug Administration.  The
    information discussed is not intended to diagnose, treat, cure, or prevent any disease.

    This website is intended as information only. The editors of this site are not medically-trained.
    Please consult your licensed health care practitioner before implementing any health strategy.

    The information provided on this site is designed to support, not replace, the relationship that
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    Contact us with comments or for reprint permission at admin@breastcancerchoices.org

Lymph Node FAQ



.

From the Manual of
Clinical Oncology
,
page 250:

"Removal of the axillary
nodes does not affect
the frequency of
recurrence, the
development of distant
metastasis or survival
rates."
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