|Scrutinizing the evidence for breast
cancer procedures and treatments
Link to medical
articles on lymph
Can factors from
the tumor biology
(pathology report )
information to allow
me to avoid axillary
No Benefit to
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.
Read excerpt from full text
To the surprise of most,
Fisher's study of 1700
patients failed to reveal any
survival advantage for
patients undergoing ELND.
Although the lymph node
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
survival advantage for
patients treated with
ELND. 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.
By DENISE GRADY
NY Times February 8, 2011
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?
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. Monica 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
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
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
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
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
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
Dr. Armando E. Giuliano, the lead author of the study and the chief of surgical oncology at the John Wayne
Cancer Institute at St. John’s Health Center in Santa Monica, 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.”
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.”
Indeed, women in the study who had the nodes taken out were far more likely (70 percent versus 25 percent) to
have complications like infections, abnormal sensations and fluid collecting in the armpit. They were also more
likely to have lymphedema.
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.”
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. Elisa 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.”
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,” Dr. Estabrook said. “Now he’s saying we
don’t really have to do that.”
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
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.”
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Web page updated January, 2012