“This is a major change,” said Dr. Dianna Craig, breast surgeon at Windber Medical Center. “Research is getting us to be less and less invasive. This is a big step along that pathway.”
Dr. Gerard Garguilo, general surgeon at Memorial Medical Center, Johnstown, said a lot of people had been calling into question the value of the more radical surgery.
“It’s a notion that a lot of us were thinking — more radical surgery was not necessary,” he said. “These are quality of life issues.”
Surgeons have been removing lymph nodes from under the arms of breast cancer patients for many years, believing it would prolong women’s lives by keeping the cancer from spreading or coming back. Removal of nodes can cause infection and lymphedema, a chronic swelling in the arm.
Now researchers report that for women who meet certain criteria, taking out nodes has no advantage.
“This is what we have to caution readers about — it is very limited, not for everybody,” Craig said.
The criteria include women whose tumors were found at an early stage, five centimeters or smaller, which is less than 2 1/2 inches across. Biopsies of one or two nodes had found cancer, but the lymph nodes were not enlarged enough to be felt during an exam and the cancer had not spread anywhere else. The women had lumpectomies. Most also had radiation to the entire breast or chemotherapy or both. An estimated 20 percent of patients, or 40,000 women a year in the United States, fit that criteria.
“The study didn’t look at women who had mastectomies, radiation of the partial breast or chemotherapy prior to the surgery,” Craig said. “It was a very limited population, but there was no difference in survival rates. We don’t have long-term data — that will come over time.”
After armpit surgery, 20 to 30 percent of women develop lymphedema. Radiation increases that to 40 to 50 percent.
“Women who develop lymphedema have arm pain, they have to limit the motion of the shoulder, they have swelling, they have to make lifestyle changes,” Garguilo said.
Craig said there is no cure for lymphedema, but it can be managed.
“The key is catching it early and using compression bandages and massage therapy,” she said. “You don’t lose the use of your arm, but it’s not fun to deal with.”
Another thing to be cautious about is that the study only included 891 patients and they were followed for just over six years.
“That is not as many women as they would have liked to have had in the study,” he said.
Dr. Armando E. Giuliano, lead author of the study, is the chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health Center in Santa Monica, Calif. The study was published this month in the Journal of the American Medical Association and in the Annuals of Surgery. The National Cancer Institute paid for the study.
The new findings are part of a trend to move away from radical surgery for breast cancer, Craig said. Rates of mastectomy, removal of the whole breast, began declining in the 1980s after surgeons found that for many patients, survival rates after lumpectomy and radiation were just as good as those who had mastectomies.
In the 1990s, 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. The theory was that if the tumor was spreading, cancer cells would show up in those nodes.
The new study doesn’t cancel out the need for chemotherapy.
“The great equalizer is chemotherapy,” Garguilo said. “It’s very effective in treating nodes that have not been removed. Radiation covers part of the nodes as well. These keep the risk of a reoccurrence (of cancer) low.”
He believes that as more studies are done it will lead to the demise of more radical surgery.
“To me, this is the next big advance in treating women,” Garguilo said.
Craig agrees that there have been a lot of changes in treatment of breast cancer in the last decade.
“This is a step in the right direction,” she said. “Right now, it’s a very limited recommendation. Women who have a diagnosis of breast cancer must discuss options with their physicians. We’re enthusiastic about the study, but cautious in going forward.”