Breast Cancer Treatment: Less May Mean More

Feb. 8, 2011— -- Some women with early-stage breast cancer who undergo less aggressive lymph node removal have as much chance for long-term survival as those who undergo more extensive removal, and avoid painful side effects, according to a study released Tuesday. It adds to the growing belief that more aggressive cancer treatment is not necessarily better.

For nearly a century, women with breast cancer underwent lymph node removal in their armpit -- known as axillary lymph node dissection -- following a lumpectomy to remove all surrounding nodes that could potentially harbor cancerous cells.

"The thought among many is that if you removed fewer than 10 lymph nodes that the treatment was inadequate," said Dr. JoAnne Zujewski, senior medical oncologist at the National Cancer Institute. "It was a widely held belief that more aggressive therapy was better; the bigger the surgery the better the care."

A growing body of evidence now suggests that sentinel node surgery alone -- which means removing only the lymph nodes closest to the tumor that test positive for cancer cells -- may be just as effective. It has fewer side effects, and may be as helpful for prolonging life.

Researchers looked at nearly 900 patients who underwent lumpectomy and either received full armpit lymph node removal or a more targeted lymph node removal. The researchers found both groups of women had a nearly 93 percent survival rate after five years, suggesting that it may not be necessary to remove whole lymph nodes in the armpits.

"I think this speaks to the power of personalized medicine and targeted therapy. We can do just as well when we treat the problem where it is," said Zujewski.

Taking out the lymph nodes subjected patients to harsh side effects with no real benefit, according to Dr. Monica Morrow, chief of the breast service at the Memorial Sloan Kettering Cancer Center and co-author of the study.

Following Morrow and her colleagues' findings, Memorial Sloan Kettering Cancer Center changed its practices. It now gives its patients less aggressive treatment, and says the results are promising.

"Research is now saying that for some women it's not necessary to go through axillary dissection and encounter the side effects," said Morrow.

But for the many women who have already undergone the more aggressive axillary dissection, the side effects are irreversible.

In 1990, after undergoing a lumpectomy in her right breast followed by an axillary dissection, Virginia Richter, 68, of Tucson, began feeling a tingle in her right arm. Her arm pain and swelling increased over time, and Richter was later diagnosed with a chronic debilitating condition called lymphedema – a common side effect for women who undergo axillary dissection.

Patients with lymphedema can experience loss of sensation in their arm and painful swelling. Many will periodically need to have built-up fluid drained, and will have go through physical therapy.

"Once you get lymphedema it's supportive care only. There's no way to eliminate it," said Zujewski. "And it's hard to predict for women how severe it will be."

Richter said at the time of her surgery, her doctors told her about the potential side effects, including lymphedema. But she said they assured her that an axillary dissection was a standard procedure to ensure that all of the cancer cells around her tumor were removed.

"When you're faced with cancer, you do what you have to do for yourself," said Richter. "As a patient you do know about side effects, but you just want the breast cancer out."

Axillary dissection should not be discounted as an important practice, said Dr. Kelly Hunt, professor of surgery and chief of surgical breast oncology at M.D. Anderson Cancer Center and co-author of the study. In fact, full lymph node removal is effective in women with more advanced breast cancer. The study focused on early stage breast cancer patients, she said.

"As we've learned more about biology of breast cancer we don't need these radical surgeries," said Hunt. "[We do] not [need to] create all this collateral damage by removing normal uninvolved lymph nodes."

Nearly a decade later, Richter said she had a short bout of cancer in her left breast, and said she opted out of a more aggressive treatment.

"[In 1990] I didn't have the option on how aggressive my treatment would be. So now, I'm living with lymphedema," said Richter. "Is it something that I like? No. But am I living? Yes."

According to ABC News chief health and medical editor Dr. Richard Besser, the study not only suggests that those who undergo less extensive treatment stand a chance to live just as long, but can also live with fewer chance of complications.

"This study is part of a major change that has taken place over time in cancer treatment. It used to be the focus was just on survival," said Besser. "Over time there has been more attention placed on the quality of life cancer survivors' experience. For some 30,000 women, this study is very exciting news."

Richter said she was unsure whether a less aggressive treatment would help keep her alive longer. But she did not want to risk having to endure the side effects this time, she said.