This story originally appeared in the Indianapolis Star.
by Shari Rudavsky
While Lisa Bott was undergoing breast cancer surgery in February, her mother-in-law texted her husband about a new study: Not every woman with breast cancer needs to have all the lymph nodes under her arm removed.
Bott’s mother-in-law had no reason to worry. Her surgeon, Dr. Thomas Schmidt, medical director of the breast program at St. Vincent Health, has been practicing restraint in node removal for some time. Lymph nodes, which are located throughout the body, help fight infection. When breast cancer spreads outside the breast, one of the first places it is likely to go is the lymph nodes under the arms.
The study, which appeared in the Journal of the American Medical Association, showed that about 20 percent of women with breast cancer do not need to have all their nodes removed, even if microscopic amounts of the disease are detected in the lymph system.
For years it’s been standard practice to remove all the nodes if cancer is detected in any one. This study suggests total node removal does not increase life expectancy. It can, however, lead to side effects such as pain, swelling and restricted motion.
“I think it gives us a lot more to talk about before we just leap,” said Dr. Chace Lottich, medical director of Community Breast Care.
The study applies only to women who have tumors no larger than about the size of a quarter with clear margins, whose breast cancer has spread nowhere else in the body, and whose lymph nodes appear normal on a clinical exam. The women in the study also underwent radiation and chemotherapy and/or hormonal therapy.
Some doctors cautioned that not every woman with breast cancer will benefit.
“It’s an excellent addition, but it’s not applicable to all patients, and we have to be very careful that patients understand that they do meet the criteria,” said Dr. Monet Bowling, a breast cancer surgeon at Indiana University Simon Cancer Center.
Bott, who did meet all the criteria, welcomed the news that she could keep her lymph nodes.
“The thought of not losing all of them sounded wonderful to me,” she said. “Everything he has shown me says my life expectancy is the same and just as good with not removing all of the lymph nodes.”
Infographic courtesy of the Indianapolis Star
Twenty years ago, women would have all their nodes removed to give doctors a better sense of how advanced the disease was, Schmidt said. About 10 years ago, sentinel node biopsy entered the scene, allowing doctors to determine if the cancer had spread outside the breast. If it had, doctors removed all the nodes.
Oncologists’ understanding of breast cancer has deepened in many other ways. Sophisticated genetic tests can now determine the chance of recurrence for some women, based on the type of their tumor tissues.
Studies started to crop up that showed that for some women, the risks of removing all the nodes outweighed the benefits, Schmidt said. He is among doctors who for some time have been leaving lymph nodes in these patients alone.
The recent study helps confirm those early indications.
“What this does more than anything is it supports and substantiates a longstanding belief,” Schmidt said. “The data wasn’t there, but the drive by women to have less aggressive, more appropriate treatment was in place with a group of physicians that were savvy in terms of how breast cancer worked.”
Not every doctor has jumped on board, however. Lottich recently attended a meeting in Miami of breast cancer experts where some participants argued that the study didn’t provide enough information to change the standard of care.
Lottich asked three experts for advice on how to handle a few of her patients. One said don’t remove any lymph nodes; another said to remove them all; and the third said Lottich should probably remove them.
“We always as patient advocates want to say let’s do no harm,” Lottich said. “This is a study that has been embraced, but I think we’re all looking for more information. With time, that will come. This gives more choices, and I always think choice is good.”
Having total lymph-node surgery can lead to trouble later on. An injury or a long plane flight even as much as 20 years after the surgery can set off swelling and pain. The increase in the number of younger patients with breast cancer makes it critical for doctors to take a long view, Lottich said.
“When you look at breast cancer and the changing face of breast cancer patients, we have a lot more women that are young and raising kids,” she said. “They need those arms. We all need our arms.”
Madonna Ruby, 51, experienced the downside of lymph removal. She knew before she went into surgery that she would need a total node removal. Lottich, Ruby’s doctor, noticed an enlarged node upon exam, leaving no other option.
Soon after the surgery, Ruby was experiencing cording, a possible side effect of lymph removal that can lead to pain and restricted movement in the arm. She’s been undergoing physical therapy as well.
But Ruby has no regrets. When the surgeons removed her lymph nodes, they tested them and found that the chemotherapy she had before surgery had eradicated all of the cancer. That helped her doctors decide no radiation was needed.
“Had they not been removed and sent to pathology, I would probably wonder,” Ruby said. “I will probably have swelling for the rest of my life, but that’s so minimal compared to, ‘I wonder if we got it all.’ ”
Since the study’s publication, Lottich has discussed the findings at length with her patients. About a third who fit the criteria to not have complete node removal have asked that they be taken out if any cancer is found.
Bott takes the opposite view.
“I want to be able to keep as much of my immune system as possible,” she said.