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Joachim Zuther, Lymphedema Specialist. Read more
Lohmann Rauscher
MediUSA

Tactile Medical

Great News for Breast Cancer Patients

 

A new study conducted by the American College of Surgeons Oncology Group, which was just published in the Journal of the American Medical Association, may significantly change current procedures on removal of axillary lymph nodes.

The study suggests that for about 20 percent of women affected by breast cancer, who meet certain criteria, complete axillary lymph node dissection (ALND) may be unnecessary, and that the surgery shows no clear benefit regarding the course of treatment, the risk of the tumors returning or spreading, or the chance of survival.

That is great news, especially in light of the post-surgical complications associated with ALND, to include wound infections, weakness in the arm, paresthesia, shoulder pain, axillary web syndrome (AWS) and lymphedema.

The objective of the trial, which included a total of 891 patients in 155 medical centers, was to determine the effects of ALND on survival (overall survival and disease-free survival) of patients with sentinel lymph node (SLN) metastasis of breast cancer. The trial was conducted between May 1999 and December 2004.

Sentinel Lymph Node

Women eligible to participate in this study had histologically confirmed invasive breast cancer in clinical stage T1-T2 (tumor size 5cm or less) with no enlarged axillary lymph nodes, and up to two sentinel lymph nodes (first lymph node or group of nodes reached by metastasizing cancer cells from the primary breast tumor) containing metastatic breast cancer.

Tangential whole-breast radiation

All patients underwent lumpectomy and tangential whole-breast radiation (radiation technique designed to include the entire breast, but the smallest possible volume of lung and heart). Those women who had metastases in the sentinel lymph nodes, which was determined by sentinel lymph node dissection (SNLD) were randomly selected to either undergo complete axillary lymph node dissection, or to undergo no further axillary specific intervention. A total of 446 women were randomized to SNLD alone, and 445 women were randomly selected to undergo complete ALND, which was defined as an anatomical level I and II dissection, including at least 10 lymph nodes. Additional systemic therapy (chemotherapy and endocrine therapy) was delivered to 403 patients in the ALND group, and 423 women in the SLND-alone group.

At a median follow-up of 6.3 years, the use of SNLD alone compared with ALND did not appear to result in statistically inferior survival. This includes overall survival, defined as the time from randomization until death from any cause, and disease-free survival, defined as the time between randomization and first documented recurrence of breast cancer. These results are in accordance with other randomized comparisons of SLND and or without ALND.

The findings are part of a trend to move away from radical surgery for breast cancer, and despite limitations of this study (no complete follow-up information on 166 women, possible randomization imbalance favoring the SLND-alone group) the results could have significant effects on clinical practice. The main indication is that women with a positive SNL and clinical tumors of less than five centimeters across, undergoing lumpectomy combined with radiation and followed by systemic therapy, do not benefit from additional complete ANLD in terms of local disease control and survival.

Implementation of this practice change could significantly improve clinical outcomes in thousands of breast cancer survivors each year by reducing possible complications, such as lymphedema, and improving quality of life with no diminution in survival.

Additional Resources:
Journal of the American Medical Association
NPR Article
New York Times Article

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8 comments to Great News for Breast Cancer Patients

  • Joy Cohn PT CLT-LANA

    The surgeons did not enroll their patients in this study until they did the sentinel node biopsy….this may have created a selection bias to entering only their lo risk patients into the study. Lo and behold- the patients across the board were at lo risk. This study also did not have information on all of the biological tumor markers that are now utilized in determining who is at lo or high risk of reoccurence. Additionally, chemotherapy treatments may have varied and data was not collected on this either. This study should NOT be regarded as the final word!

  • Robin

    I wanted every single thing removed and if I had taken a chance and had a recurrence what then?
    I would rather have lymphedema!

  • D Williamson

    Since having lymphedema since day one of stage 1 cancer as well as ductual insitu cancer, I would not wish it on my worst enemy. There were over thirteen lymph nodes removed. It has caused lymphatic difficulties in the full upper left quadrant of my body. This is my 15 survival year, with many ups of lymphedema.

  • Julie Bajema

    This is not related to breast cancer surgery, but is related to lymphedema. I am a certified lymphedema therapist and one of the physicians I work with asked if I knew anything about Naltrexone. There are some claims that in low doses, 1.5 – 4.5mg, that it may boost the immune system and relieve some lyphmedema. Does anybody have any other information or experience with this? What are the side effects? Thank you!

    • Joachim Zuther

      Dear Julie:
      I was unable to come up with useful information on this issue, but will continue to ask around.

  • Julie Bajema

    Thank you!

  • Karen

    Does this apply to mastectomy patients or just to lumpectomy patients?

    In Nov. 2012, I had a bilateral mastectomy and SNLD. Surgeon found 10 SN’s (yes, 10!), so he removed all 10. One was positive, but not enlarged. I was told I had to do an ANLD, so 10 days later I had another 13 nodes removed. I got lymphedema less than 2 months later in my right arm (dominant arm). Did my surgeon do the right thing? My cancer was 3.5 cm. I am 45 and was an athlete prior to lymphedema.

    • Joachim Zuther

      Dear Karen: This applies to both mastectomy and lumpectomy patients. I am sure you understand that I am unable to comment on the question in regard to your surgeon. However, I am confident the correct decision was made.