Axillary Lymph Node Dissection for Breast Cancer May Not Be Necessary

Welcome to Weekly Health Update


“A critical weekly review of important new research findings for health-conscious readers”



AXILLARY LYMPH NODE DISSECTION FOR BREAST CANCER MAY NOT BE NECESSARY

The management of breast cancer has undergone many advances since the radical mastectomy that first came into popularity in the United States in the late 19th century.  At that time, even early cancers of the breast were managed by surgically removing the entire breast, the underlying chest wall muscles, and all of the lymph nodes under the armpit (axilla).  It wasn’t until the 1970s that surgeons began to abandon radical mastectomy, in favor of the less disfiguring modified radical mastectomy, based upon emerging research data at the time.  By the 1980s, additional research data had confirmed that women who underwent lumpectomy plus radiation therapy experienced equivalent survival when compared to women who underwent mastectomy.  In the late 1990s, another major paradigm shift in the surgical management of breast cancer occurred with the rapid adoption of sentinel lymph node (SLN) biopsy, which had previously also revolutionized the surgical management of melanoma.  Following the successful application of SLN biopsy to breast cancer, the 60 to 70 percent of women with breast cancer who have normal axillary SLNs (i.e., no evidence of spread of breast cancer cells to the lymph nodes in the axilla) could now avoid undergoing complete axillary lymph node dissection (ALND), wherein about two-thirds of the armpit lymph nodes are surgically removed.  As the risk of arm swelling (lymphedema), numbness, and other long-term side effects associated with ALND are only one-tenth as common following SLN biopsy, the majority of women undergoing breast cancer surgery over the past decade have been able to avoid many of the chronic complications and side effects associated with the more radical surgical approaches used in the past.  However, between one-fourth and one-third of women diagnosed with breast cancer will still be found to have tumor cell in their SLNs, and most of these women have routinely been advised to undergo ALND to remove additional armpit lymph nodes.

Now, a newly published clinical research study from the American College of Surgeons Oncology Group has, once again, dramatically shifted the paradigm of breast cancer management.  This clinical research study, which I was privileged to participate in when I was a Surgical Oncology Fellow at the John Wayne Cancer Institute, enrolled 891 women newly diagnosed with breast cancer, and with early metastatic cancer involving one or more of their axillary SLNs.  These women were evenly randomized into two groups.  One group underwent the standard therapy of ALND, while the other half of these patient volunteers were observed, without further surgery, following SLN biopsy.  The results of this pioneering breast cancer research study appear in the current issue of the Journal of the American Medical Association.

After an average duration of patient follow-up of more than 6 years, this pivotal clinical study has confirmed what many of us oncologists have long suspected.  In women with evidence of microscopic spread of breast cancer to one or more axillary SLNs, there was no difference in overall survival whether or not they went on to undergo ALND, as long as they underwent otherwise standard therapy for lymph-node-positive breast cancer (including lumpectomy, radiation therapy to the breast, and chemotherapy).

I cannot overstate the potential impact of the findings of this important clinical study.  However, while some have heralded the findings of this study as breaking important new ground, in fact that ground was broken by the very same pioneering prospective clinical research study (the National Surgical Adjuvant Breast and Bowel Project’s NSABP B-04 study, which began in 1971) that originally led surgeons to abandon radical mastectomy.  Within this older large prospective clinical study was an important subgroup of 586 women with palpably enlarged axillary lymph nodes (and which actually indicated a more advanced stage of lymph node involvement than the women who participated in the more modern American College of Surgeons Oncology Group study).  Like all of the women who participated in the NSABP B-04 study, these 586 breast cancer patients with enlarged armpit lymph nodes were randomized to undergo radical mastectomy with radical ALND versus mastectomy alone (and no lymph node surgery at all ) combined with radiation therapy.  After an average follow-up of 25 years, there wasabsolutely no difference in survival between the women who underwent radical lymph node surgery combined with radical mastectomy versus those women who underwent simple mastectomy alone (and no lymph node surgery) followed by radiation therapy.

Thus, the newly reported findings of this pivotal American College of Surgeons Oncology Group clinical study only further validates the findings of the nearly 40 year-old NSABP B-04 study, and should put to rest, once and for all, the decades-old debate about the role of surgery in the management of the axillary lymph nodes in patients with newly diagnosed breast cancer.  At a minimum, surgeons should now advise their breast cancer patients that there is now 40 years worth of high-level clinical research data showing that the surgical removal of most or all of the armpit lymph nodes (ALND) does not improve survival in women who otherwise undergo standard breast cancer treatment that includes lumpectomy (or mastectomy), chemotherapy, and radiation therapy.

I predict that the findings of these two landmark breast cancer surgical studies will, together, once again revolutionize the surgical management of breast cancer, and will further reduce the adverse impact of surgery on hundreds of thousands of women around the world each year.  Indeed, this latest revolution in the management of breast cancer has already started at major cancer centers in the United States, where women are already being advised that the finding of early spread of breast cancer cells to their axillary SLNs no longer mandates “completion ALND,” as long as these patients undergo standard chemotherapy and radiation therapy following lumpectomy and SLN biopsy.


For a complete discussion of evidence-based approaches to cancer risk and cancer prevention, order your copy of my new book, A Cancer Prevention Guide for the Human Race.  For the price of a cheeseburger, fries, and a shake, you can purchase this landmark new book, in both paperback and e-book formats, and begin living an evidence-based cancer prevention lifestyle today!


For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my new book, “A Cancer Prevention Guide for the Human Race,” from AmazonBarnes & NobleBooks-A-MillionVroman’s Bookstore, and other fine bookstores!


On Thanksgiving Day, 2010, A Cancer Prevention Guide for the Human Race was ranked #6 among all cancer-related books on the Amazon.com “Top 100 Bestseller’s List” for Kindle e-books! On Christmas Day, 2010, A Cancer Prevention Guide for the Human Race was the #1 book on the Amazon.comTop 100 New Book Releases in Cancer” list!



Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity




Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author




For a different perspective on Dr. Wascher, please click on the following YouTube link: Texas Blues Jam



I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people, from around the world, who visit this premier global health information website every month. (More than 1.2 million health-conscious people visited Weekly Health Update in 2010!) As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.







Bookmark and Share




Post to Twitter

Enter Google AdSense Code Here

Comments

10 Comments on "Axillary Lymph Node Dissection for Breast Cancer May Not Be Necessary"

  1. Sarah G P on Mon, 30th May 2011 2:47 pm 

    If some of the more drastic treatment of bc has been discontinued, who knows whether other types of treatment may alsobe found to be unnecessary?

  2. Ekskavaator on Tue, 16th Aug 2011 1:03 am 

    Thumbs up for this!

  3. Lisa on Fri, 26th Aug 2011 10:31 am 

    Anything that gives patients a chance to make informed choices is very welcome. Thank you.

  4. Kellad on Tue, 30th Aug 2011 2:43 am 

    Hey There. I found your blog using msn. This is a really well written article. I’ll be sure to bookmark it and come back to read more of your useful info. Thanks for the post. I will definitely comeback.

  5. McKown on Tue, 30th Aug 2011 2:52 am 

    Wow, wonderful blog layout! How long have you been blogging for? you make blogging look easy. The overall look of your site is great, let alone the content!

  6. Cora on Sun, 16th Oct 2011 10:14 pm 

    Excellent read, I just passed this onto a colleague who was doing a little research on that. And he actually bought me lunch because I found it for him smile So let me rephrase that: Thanks for lunch!

  7. Angelique Facundo on Fri, 23rd Dec 2011 5:40 am 

    Awesome writing style!

  8. AtTheEndOfMyCord on Sun, 19th Feb 2012 9:15 am 

    Thank you for this evidence-based info written with the patient in mind. I had bilateral MRM, ALND, and immediate reconstruction in July 2011 at a top five institution in the U.S. Two out of the 19 lymph nodes removed were positive, so onc surgeon removed all at time of surgery. Along with other surgical complications, the ALND has been an ongoing nightmare since.

    Can you please tell me why oncology surgeons are not telling their patients about the possibility of ALND causing axillary webbing/cording during consultation and adding it to the consent form? My surgeon discussed all possible complications such as nerve damage, bleeding, and lymphedema. There was absolutely no verbal discussion or patient education materials about axillary webbing/cording. ALND is a major cause of this phenomenon. Axillary webbing is NOT rare either according to my phyical therapists and the thousands of women on discussion boards.

    My case has turned into severe, refractory, and painful cording. I started with prescribed exercises following surgery. I could not start PT until all six drains were out, so I started PT 23 days post-surgery. When radiation onc examined me during consultation on day 21, he said he could not start radiation until PT could get my arm back to a certain degree for the beam. It took about 4 weeks and 12 appointments to get it back just far enough in position for beam, but a mold had to be made because my arm could not lay back flat behind my head because of the restriction from the axillary webbing.

    I am now 8 months post surgery, and have completed over 50 physical therapy sessions. PT’s have given up on the thick, hunk still growing out of my ALND incision. PT’s did all treatments including snapping/popping numerous individual cords attached to my elbow and wrist. I have been seen by a physiatrist at the rehab/lymphedema clinic at this major instition. I also have chest wall lymphedema. There is not enough space here to report the other problems I had from the nine hour surgery with a 7 hour mastectomy and 2 hour immediate full implant reconstruction problems.

    My QOL of life has been severely impaired by ALND. It certainly would have helped knowing about this BEFORE surgery. I am not the only patient who is upset the lack of notice about axillary webbing/cording caused by ALND. I am now going to see a surgeon at another top five institution who has successfully performed surgery on refractory cording.

    Can you please advocate for major patient education about axillary cording???

    Also, what is you take on lymph node transplant?

    BTW, great blog!

    Sincerely,
    AtTheEndOfMyCord

  9. admin on Sun, 19th Feb 2012 10:54 am 

    Thank you for sharing your experiences.

    Axillary webbing/cording after ALND is actually very uncommon; however, if it happens to you, then it becomes a “100% risk” in your case. Have you seen a plastic surgeon who specializes in breast reconstruction? If not, then this would be my suggestion.

    As for free lymph node transplantation, there have been a handful of small retrospective clinical reports that suggest this approach may provide durable, long-term lymphedema improvement in selected patients. However, until a well-designed prospective randomized clinical trial reports long-term results with this procedure, I would have to describe it as an investigational procedure at this time. (It might still be something for you to look into, however, particularly if you are close to one of the centers that have retrospectively reported on their results with this procedure.)

    In the post-ACOSOG Z-11 trial era, I am no longer recommending ALND for patients who have 2 or fewer positive sentinel lymph nodes, as long as they fit the following clinical criteria: lumpectomy and sentinel lymph node biopsy followed by whole breast irradiation, and chemotherapy or/and hormonal therapy.

    I wish you well, and I thank you for your thoughtful comments.

    Sincerely,

    Robert A. Wascher, MD, FACS

  10. AtTheEndOfMyCord on Sun, 19th Feb 2012 11:31 am 

    Thank you for your immediate response Dr. Wascher!

    The majority of reconstruction plastic surgeons are speechless about what to do about cording. The plastic surgeon who did my immediate reconstruction (top 5 institution) literally sat there speechless and made no offer to research or find help for me. (He also didn’t offer how he could help with revision of his own surgery.) I have been researching this for months. A patient should not have to do this. I finally found a surgeon at JH (who was so kind & actually emailed and called me) and have an appointment in two weeks. There are 2 surgeons at MSK and 1 at MDA-Orlando that perform surgical intervention as well. I’m sure there are more, I just checked with 3 major institutions.

    Can you please, please advocate this at conferences and through your associations?

    I have to disagree that AWS is rare; however, I agree that it is rare to be severe and refractory to treatment such as mine. Nevertheless, breast cancer patients are suffering from this very real complication of ALND. I found a patient education brochure titled “Exercises after breast surgery” published by the Canadian Cancer Society. It even had a page about Axillary Webbing! Patients are out there in shock of what has happened with no direction from onc or plastic surgeon. The PTs at my local hospital say they never go a week without working on a breast cancer patient’s webbing/cording.

    I think surgeons aren’t educated about this because they are “done” with their patients as soon their one week follow up appt is over. The cording usually hasn’t developed until a few weeks after surgery. Should you be interested, Google “Step Up-Speak Out” a website for lymphedema advocacy that includes info on AWS.

    Just informing your next patient pre-surgery about this risk is a step toward helping breast cancer patients coping with aftermath of cancer.

    Respectfully,
    ATEOMC

Better Tag Cloud