Node Removal
February 8, 2011
Lymph Node Study Shakes Pillar of Breast Cancer Care
By DENISE GRADY
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.
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 the study.
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 after surgery.
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 other places.
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.
Comments
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deleted by evebarry...Diagnosis: 1/7/2011, IDC, Stage I, Grade 1, ER+/PR+
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eve,
when my mother was wheeled into the surgery room, she was her feisty --confident self.. but after surgery-- she was never the same-- it broke me to pieces..
after that , she had become more determined not to go for conventional treatements without question or without knowing all the odds..
without my or my mother's knowlede they also took 25 LYMPH NODES!! 25! it took us 3 months to get my mother out of the fear of lymphedema..
my mother, took TCM medicine (from the TCM clinic supported by the same hospital) for 5 days, pure Cranberry Juice, turmeric juice-- and she was cooperative with the physio therapist.. very determined to do all the exercises despite the challenges..
after 3 months, I enrolled her for a taichi class- the teacher, would go to our house twice weekly..
and of course her rebounding 5 minutes a day---plus dry brushing (I both natural bristles and did it for her-- as she cant reach some parts of her body)
you might want to consider-- sorry, I have not done much research on lymphedema...
***I am not a health professional so take everything I say as opinion and not fact. Consult your health professional for medical advice.**
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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.
So what is the criteria? The article says many women (but not all) could forgo lymph node removal and the above quote from further in the article says 20% don't need it. So 80% still do?
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Thanks, Timothy! As usual, a very reasoned post with excellent summary!
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http://www.breasthealthandhealing.org/socialnetworking/messages/20110308.html
Say "Good-Bye" To Axillary Dissection'' by Kathleen Ruddy, MD
For more than one hundred years, surgeons have gone through the axilla like Grant went through Richmond. They mistakenly believed that removing lymph nodes in patients with breast cancer would improve their survival. It did not, but still they took out every node in sight, sometimes even going up into the neck in their exuberant determination to cut out the cancer. Despite this near religious fervor for extensive surgery, it was pretty clear by the 1970s that axillary dissection did not, in any way, improve survival, and yet the scorched axilla policy remained the gold standard for breast cancer care.
Then in the 1980's, the number of lymph nodes involved with breast cancer helped determine the type of chemotherapy patients might receive. During this period of time, axillary dissection was useful, but again, it did not confer a survival advantage: patients lived or died regardless of what you did to the axilla. But it did help tailor chemotherapy treatments, so it was useful in that regard.
Then, in the 1990's we learned something else: the vast majority of women whose tumors were larger than 1.0 cm benefited from chemotherapy; so, what, then was the point of digging around trying to determine the number of positive lymph nodes if the majority of women would be getting chemotherapy depending on tumor size, not lymph node status? This was a good question without a satisfactory answer for most surgeons and medical oncologists refused to believe the data from the 1970's that clearly showed that axillary dissection produced no survival benefit.
In 1994, a half-way house for axillary dissection was established with the introduction of sentinel node biopsy: the idea was to just look at one node, if it was negative, then the surgeon would leave the remaining lymph nodes alone; if it was positive, then the surgeon would take all remaining lymph nodes, even if they were most likely to be cancer-free. But again, the problem was: if there is no survival advantage to axillary dissection, and if chemotherapy is determined by the size of the tumor, then what's the point of even a sentinel node biopsy? And still, the surgeons went into the axilla like old generals fighting the last war. So another study was created to test the survival benefit of even a sentinel node biopsy, and the results confirm what we knew back in the 1970's: it doesn't matter what you do to the axilla, so leave it alone!
Axillary dissection, RIP, at last!......
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Here is some more information:
Axillary lymph node dissection did not improve overall survival or disease-free survival in women with T1-T2 breast cancer who were found to have limited metastasis on sentinel node dissection, according to a report in the Feb. 9 issue of JAMA.
My understanding is that if a woman has a T1 or T2 tumor and is found to have only microscopic metastasis in the sentinal nodes, then no further axillary dissection is necessary (does not improve survival, even if it further axillary dissection gives more information). Chemotherapy and radiation are effective treatments for microscopic metastasis in this case.
The study does not suggest in any way that sentinel node dissection is unnecassry for coming up with treatment options. It also doesn't suggest that widespread metastasis to the nodes shouldn't be treated with axillary dissection.
I didn't have a sentinel node biopsy. I had 13 nodes removed, all clear so if I had had a sentinel node biopsy, there would have been no further axillary dissection anyway since I had no cancer cells in my nodes. However, now even if there is a small amount found in the sentinel nodes, there saying no more surgery is necessary. Fortunately, I do not have lymphedema - thank goodness.
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Eve, I agree you would have been happier not to have the SNB. Your doctor should have met with you first to discuss this even if it was in the prep room since you had indicated doubt.
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I was thinking about this node dilemma and wondered about those like me who had no obvious sign of node involvement yet I had 9 nodes affected. On second thoughts I did have swelling which I guess was a clue that the nodes were blocked but this clue might not be present for others. Without a SNB I don't see how they can decide what stage we are. If I'd had a SNB and all were found to be cancerous, would they then take the lot? I know some women have had microscopic tumours but many nodes, yet they would not be treated for the nodes without a SNB, thus risking spread from the nodes.
Researchers have said that cancer stem cells are the main method of spread and they are unaffected by chemo or radiation. If that is proven by further studies to be true, then we would need to know if the nodes contain cancer stem cells in which case they would need to be surgically removed. It seems this is not a simple matter. If only it were straight forward.
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I'm glad to know that my nodes were negative. I still had to have chemo owing to the HER2+ve reading, but if that had not been the case no chemo would have been required. So I don't see any sense in not doing an SNB as it would determine the subsequent treatment.
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I am never angry about improved understanding and treatment. I had the full axillary dissection and I'm glad that many women now can avoid it, but I would never call myself a victim. There are always studies that lead to changes in treatment. I was treated six years ago, I would hate for what I received -- the gold standard at the time -- to still be the gold standard now.
I was never forced to do anything. And BTW my understanding is that these findings only apply to women with micromets in their sentinel node, not to women who were fully node positive like myself. Micromets in the sentinel nodes has always been a grey area. back when i was diagnosed many did not consider it to be a positive node at all.
I have lymphedema and it is by no means worse than a more aggressive cancer. My diagnosis was delayed a year so a more aggressive cancer would have meant I wouldn't be here. My LE therapist told me that in her LE support group its the women who don't have LE, who are afraid of it, who are much more distressed than the women who actually have it.
Progress is great. It doesn't make me angry at all.
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I am never angry about improved understanding and treatment. I had the full axillary dissection and I'm glad that many women now can avoid it, but I would never call myself a victim. There are always studies that lead to changes in treatment. I was treated six years ago, I would hate for what I received -- the gold standard at the time -- to still be the gold standard now.
I agree. I was treated only a few years ago and things are already changing from then. I think that is a great sign. To me, that means progress is happening faster.
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I apologize for what I said about LE being compared to aggressive cancer. I should had been more sensitive.
If you read above, I am talking about, as this article also refers to node removal for early stage cancer.Dx 2007 & 2008 with high grade como-neu dcis...multifocal...2011 mucinious stage 1 cancer. Es & Pr 3 +++
Diagnosis: 1/7/2011, IDC, Stage I, Grade 1, ER+/PR+ -
Eve I'm not saying you have no reason to be concerned. I was just giving my reaction to the new study.
BTW, you might want to post about your situation in the lymphedema section -- there are some women with extraordinary expertise over these.
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Member...The only reason I come back to bco lately is to visit the lymphedema sectiion. I try not to click onto the alternative threads but sometimes, the temptation has been too great.
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Help me here. How would I have known that I am truly Stage 1 and didn't need chemo without proof of a negative sentinal node? (or that damned axillary dissection when the sentinal wouldn't light up due to scar tissue?)
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WOW, I really hope that the women like me who have dealt with agressive cancer don't read this, I am very sure most of them
would take LE any day over there agressive cancer. Here's the deal, ultimately node involvment or
not BC is very sneaky. The reason surgeons fight this new theory is bc there # 1 goal is to save a persons life. I have a very mild form of LE, and I had a very agressive form of cancer! Double wammy! Trust me you would take the LE over aggresive cancer! I go to LE theropy, I take my tamoxifen, I have had my ovaries out at 41, and they threw the book at me with chemo and rads. I thank God each and every day that I am here to see my kids grow up, and pray I will grow old with my husband. Big arm or not, I just want to grow old with my family, thats all that matters. I trust my BS treated me the way God intended my cancer to be treated. I don't mean to sound harsh about this, but I have seen so many women not survive this beast, I think you have to
decide with this new info what is the best treatment for you. Please don't base your treatment on
if you will get LE or not .They did not think I had lynph node involvment, read my signiture,
do you think they made the right decision to take 17 nodes? I do. Thats just my uneducated opinion!
At the end of the day we only have so much control over this.
Blessings to all that are on this journey.
Faithfulheart
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Faithfulheart, anyone with a most 4 cm tumor would be considered advanced or worrisome and in your situation it would not be a question not to take out the nodes. The premise of this article is for those with early cancers. (early cancer, dcis, stage 1...small tumors).
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I'm confused, We are talking about node removal and LE. What about the women with very small
tumors and lots of nodes, would this new treatment apply. You can have a 1cm tumor with lots of nodes "advanced cancer" or you could have a 6cm tumor with no node involvment right?
I was refering to the LE verses no LE when choosing a treatment plan. I have a friend who went from a stage 1 to a 4 with no node involvment, it just went everywere else instead. I know I SHOULD PROBEBLY NOT BE GIVING MY OPINION ON THIS TREAD, However it was up at the top under new topics, I really do try to stay off this tread. Sorry if I offended anyone.
God bless you all
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If you read carefully, the new evidence also does not apply to women who show any clinical evidence of node involvement before surgery no matter what the size of tumour on biospy.
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I think there are two things going on here. Eve is rightfully angry at the way she was treated. The new findings might apply to her, but they don't apply to most of us who had node-positive bc. Or the real possibility of node positive bc. My sense is that they aren't moving away from the sentinel node biopsy, just from the full axillary dissection for women with micomets in the nodes. This is an extremely limited universe. It may be that in the future they can expand this universe as things like oncotype testing replace traditional staging. But we aren't there yet.
I hated the idea that any cancer might be left in my body and asked the radiation oncologist to radiate my lower level of nodes, since I had a positive one. This is not why I got LE, BTW. I had an old hand injury and surgery on my hand, so my lymphatic system was already compromised and the bc pushed it over the edge -- my LE is in my hand.
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Thank you MOC. This study is not about doing away with SNB. It's about not doing axillary dissections when there is a positive node, just to see how many more are positive.
I had to have a SNB to make sure my 1 cm mass was Stage 1. Any positve nodes would have put me at a higher Stage and totally changed my treatment plan.
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I just posted this in the other thread, but I'll paste it here since it applies to this thread too.
"Think Twice Before Removing your Nodes" I absolutely agree, and don't think anyone would DISagree. However, the article posted is very skewed, oversimplified, and sensationalized.
Evebarry, I understand you're frustrated by your experience of feeling tricked and coerced into having lymph node removal, but that may be more of a statement of personnel and/or policy issues at your treatment center than a statement about the procedure in general. I honestly think you should file a complaint with your center about your dissatisfaction with your care, since no patient should ever feel forced or tricked to do anything, and if your providers went beyond your level of consent, that should definitely be investigated.
However, the issue of lymph node removal is far from as black and white as it's being made out to be. The article posted implies that node removal is BAD, and it's just not that simple, especially when even that article says, "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."
Research is ongoing to determine best practices and at this point, based on current data, that lymph node removal is still the best option for SOME patients but not recommended for SOME others. As with most everything else related to BC treatment, it's an art - not a science. There is no black and white one-size-fits-all answer.
Of course lymphedema is a very real concern, and care should be taken to avoid it. That's why the ongoing research to narrow down exactly which patients have which risk/benefit profiles.
It bothers me when I see scare tactics such as this New York Times article being used to imply that a certain procedure/drug/treatment/whatever is good or bad for breast cancer patients. If only it were that simple.
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hi eve,
I truly believe that scientists are now really being true to the Hippocrates oath, there are already challenging their own previous assumptions...
they are more patient focused now instead of protecting their own image as 'know it all'.
I do believe that all of the old practices being corrected today, should not make us angry-- as scientists/doctors are infallible human beings like you and me.
however, I would also shout it out to the world if I know these latest advancements -- like you did.
and it would also be to our benefit to accept new ideas like this-- whether or not the media took a hype on it
we know how to parse absolute truth anyway.. its not as if you read the article and made a big deal out of it -- you experienced the ordeal yourself, my mother experienced it herself...
the double jeopardy
1. if we talk about malpractices that are not --acknowledged by the medical world (they ask as for clinical trials)
2. now that clinical trials are available -- and it seems this time around the media is on our side ( they say we are over reacting..)
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Sorry for even starting this thread...I suppose I just needed to vent. But...again...so many of you are not actually reading the article in that it is talking about those who have early stage cancers. A similiar article was in my local newspaper.
Also...my surgeon is a sweet person. I wouldn't do anything to hurt her...I'm sure she thought what she was doing was best for me. It's just that so many surgeons consider removing nodes "standard care" for any cancers that are invasive. I'm moving on from all this.
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eve, I'm not sorry you started this thread. This was a topic I really had to grapple with at the time of my lympectomy. My BS wanted me to agree to removing as many nodes as he felt were needed if the SNB was positive. I told him no way would I give hime that freedom while I was asleep. I wanted to make that decision while awake if it came back positive. I feel many of us are feeling so scared at that time we often will go along with things we may regret later on. I do know there are questions as to the need to remove level 1 and 2 nodes if positive. I just wnted the choice if it came down to that.
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