Sarah Beth Snell, MD, a surgical oncologist
Latest Research on Lymph Node Dissection with Lumpectomy
Extensive Lymph Node Removal For Early Stage Breast Cancer?
A nationwide study published in the February 9, 2011 edition of the Journal of the American Medical Association (JAMA) stated that many women with early stage breast cancer do not automatically need to have all cancerous lymph nodes removed from their armpit as part of their surgical treatment plan. Removal of lymph nodes has long been considered the standard practice to keep cancer from recurring or spreading to other parts of the body. The JAMA study, funded by the National Cancer Institute, found that removal of cancerous lymph nodes had no significant impact on survival rates because women often had post-surgery chemotherapy and radiation anyway, which likely killed cancer cells.
Sarah Beth Snell, MD, a surgical oncologist who specializes in breast cancer surgery at St. Anthony's Medical Center, and an assistant professor of general surgery at Saint Louis University School of Medicine, says the report has generated questions and differing opinions among breast cancer patients and cancer specialists.
Says Dr. Snell:
The recent study in the Journal of the American Medical Association found that in limited cases — early stage breast cancer where there also was evidence of limited sentinel node involvement— removal of just one or two of the sentinel nodes appeared to be as effective as a more invasive procedure that removed significantly more (or all) lymph nodes. That's because both groups also underwent chemotherapy, hormonal therapy, and/or radiation as part of their post-surgical treatment plan.
The study is significant because extensive removal of the lymph nodes requires a longer recovery time, is sometimes painful, and can have complications such as lymphedema, a chronic, painful swelling of tissues under the arm.
Patients diagnosed with early stage breast cancer should discuss their treatment options closely with their medical oncologist and breast surgeon. While the study has generated headlines, it really focuses on a specific diagnosis — patients only with early stage breast cancer who have evidence of little spread to the closest lymph nodes to the breast (the sentinel nodes) and who elect to undergo a lumpectomy.
The definitive method to determine the spread of cancer cells has been to perform a surgical procedure called an axillary dissection, which involves making a surgical incision in the armpit to remove lymph nodes for laboratory examination and to gauge both the stage of breast cancer as well as the risk for recurrence. If cancer is detected, surgeons typically remove more lymph nodes. Following lumpectomy and axillary dissection, patients would undergo radiation and/or chemotherapy and/or hormonal therapy.
The study published in February 2011 found that patients with limited sentinel lymph node metastatic breast cancer treated with lumpectomy and post-surgical hormonal therapy, chemotherapy and/or radiation did not have worse survival rates than those who underwent the full axillary dissection of lymph nodes as part of their treatment plan.
In counseling patients with early stage breast cancer, we go over multiple treatment options, including lumpectomy, mastectomy, and any post-surgical treatment plans involving radiation, chemotherapy and/or hormonal therapy. While there are times when women do not need a full axillary dissection of lymph nodes prior to post-surgery treatment, I caution patients to listen closely to what their surgeon may say about whether their particular cancer really is comparable to what was identified in the study. There are differing opinions in the medical community as to what is the true definition of “limited” sentinel node involvement when reviewing this study.
For my patients, I take a highly individualized approach. There are cases when I would recommend removal of only one or two sentinel nodes; however, there are other cases when I would strongly recommend that more lymph nodes be removed to prevent an increased risk of recurrence or spread of the breast cancer.
When studies like these are published and circulated in the media, it's important that patients discuss the studies with their cancer team and listen to the rationalization of why the team recommends a specific course of treatment. In almost all cancer programs across the country, cancer treatment is handled in a multi-disciplinary approach, with radiologists, pathologists, surgeons, medical and radiation oncologists and other cancer specialists all coming together with their considerable expertise to discuss every patient's individual diagnosis, medical history, laboratory tests and imaging results. The team also keeps up-to-date with all of the latest research and cancer clinical trials.
Breakthroughs in cancer care and treatment occur regularly, with new medications and therapies identified for many different cancers. As patients educate themselves on the latest options, they should firmly believe they have a true partnership with their cancer treatment team to obtain the best outcomes.
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