When it comes to cancer, the general idea is less is more. The fewer tumor and malignant cells that are left behind by treatment, the greater the chances of surviving the disease.
Now a groundbreaking study shows that in some cases of breast cancer, the same philosophy may hold true for treatment, with less aggressive treatment leading to the same survival benefits as more invasive care.
In a study published in the Journal of the American Medical Association by researchers from more than 100 cancer centers across the country, scientists report that removing lymph nodes in women with early stage breast cancer did not improve their chances of surviving or avoiding a recurrence, compared with leaving the nodes behind during cancer surgery.
After five years, women in both groups — those who had several lymph nodes removed, and those who had only one or two excised (those nodes that were initially tested for the presence of cancer) — had about a 92% chance of survival.
The results were not a complete surprise to the study authors, who embarked on the trial after consulting previous studies that showed that the majority of women who had all of their lymph nodes removed did not actually have cancer in these regions.
“It was part of Dr. Armando Giuliano’s thinking,” says Dr. Monica Morrow, a co-author of the paper and chief of the breast service at Memorial Sloan Kettering Cancer Center, of the trial’s lead investigator. “He recognized that in 60% to 70% of women, the nodes were not involved, so why take them all out?”
Removing lymph nodes makes sense, particularly for breast cancer, since the lymph can harbor wayward cells that travel out of the original tumor into other parts of the body. Because the breast tissue lies close to the lymph nodes under the arm, removing the 20 or so nodes along with the initial breast tumor became standard of care for treating breast cancer. But as medical knowledge and technology improved, such a better-safe-than-sorry approach seemed too aggressive for some cases.
For example, in recent decades, doctors have learned that removing only part of the breast, with a lumpectomy, and following that surgery with radiation, leads to similar survival outcomes as a mastectomy, or removal of the entire breast. Also, with the recognition that not all lymph nodes are created equal, and that certain ones, known as sentinel nodes, can serve as bellwethers for whether cancer cells have migrated beyond the breast, doctors have been able to limit surgery to just these sentinel nodes.
These advances, coupled with the fact that mammography screening is helping women to pick up their cancers earlier, before they spread to the nodes, makes it possible to begin re-thinking traditional approaches to the disease.
Bypassing the full removal of the lymph nodes may take some getting used to, especially for women who worry that they may not be doing all they can to prevent recurrence or spread of their disease. But cancer experts at Memorial Sloan Kettering and MD Anderson Cancer Center, two of the study sites, have already advised women who qualify to opt for the lesser surgery. And the response, surprisingly, has been positive. “In terms of discussing this with women, years ago when we discussed lumpectomy versus mastectomy, everybody believed that mastectomy was the better cancer treatment because it’s the bigger surgery,” says Morrow. “For many years, it was a hard sell for patients. But the experience with lymph nodes has been completely different. Most of them are pretty good with this,”
That may be because the side effects of lymph node removal include lymphedema, an irreversible swelling of the arms that is difficult to treat and can affect a patient’s quality of life, making it hard for her to button a blouse at the wrist as well as cause pain and discomfort. Anywhere from 25% to 30% of women can be affected by lymphedema, and many have to wear compression garments to keep the swelling down. “Every women I discuss lymph surgery with, the first thing out of their mouth is, ‘Am I going to get lymphedema?’” says Dr. Kelly Hunt, chief of surgical breast oncology at MD Anderson and a co-author of the study. “They have seen it in enough of their friends, neighbors and relatives to know what it is, and are scared of it.”
That’s why the trial’s findings are particularly welcome, since about 20% of women diagnosed with breast cancer may be able to avoid having all of their lymph nodes removed. The option is not for everyone, however — the study focused on women with early stage cancer whose disease had only spread to one or two lymph nodes, if at all. And it may take a while for the idea that less is more to sink in, especially in cancer care. “Patients may or may not be ready because we have been taught that with surgery, radiation and chemotherapy, more is better,” says Liz Thompson, president of Susan G. Komen for the Cure, a breast cancer advocacy and research organization.
But results like these highlight the fact that medical care is becoming more refined and personalized, and that patients have many more options for treating their particular disease than ever before. “Women are understanding that one size doesn’t fit all any more,” says Hunt. “And that we have to tailor our treatments for individual patients.”