Normally when I reprint an article or study for PSA purposes I don't include, within the text, my own editorial comments. In this case, with this study, I feel compelled to throw my "two cents" in ... smack dab in the middle of the reporting. My comments, editorials, opinions, etc are noted in italics. Read on...the "dogma is strong!"
By DENISE GRADY (February 8, 2011 - NY Times)
A new study finds that many women with early breast cancer do not need a painful procedure that has long been routine: removal of cancerous lymph nodes from the armpit.
|Medical diagram of SNB Prep|
The discovery turns standard medical practice on its head. Surgeons have been removing lymph nodes from under the arms of breast cancer patients for 100 years, believing it would prolong women’s lives by keeping the cancer from spreading or coming back.
One would think that after 100 years of post-surgical study that this "new" information / possibility / probability should have, could have been discovered / explored sooner. The latency of this revelation, in and of itself, is greatly disturbing. And there is the tiny little fact that DESPITE having had a SNB; and DESPITE the fact that I did have one positive node but current medical protocol was to ignore it as a "false positive" -- attributable to the SNB itself...nearly two (2) years to the day it is confirmed that my breast cancer has indeed spread into my lymphatic system. What does this mean? Well, because of the active lymph nodes being so close to the primary tumor site, there is a very high probability that distant organs are affected. The challenge with ILC is, however, that it is difficult to early detect any potentially affected organ because until the invasive forms into a detectable mass. Which is my cancer hx thus far.
Now, researchers report that for women who meet certain criteria — about 20 percent of patients, or 40,000 women a year in the United States — taking out cancerous nodes has no advantage. It does not change the treatment plan, improve survival or make the cancer less likely to recur. And it can cause complications like infection and lymphedema, a chronic swelling in the arm that ranges from mild to disabling.
|Example of lymphedema|
patient with a medical sleeve
Removing the cancerous lymph nodes proved unnecessary because the women in the study had chemotherapy and radiation, which probably wiped out any disease in the nodes, the researchers said. Those treatments are now standard for women with breast cancer in the lymph nodes, based on the realization that once the disease reaches the nodes, it has the potential to spread to vital organs and cannot be eliminated by surgery alone.
Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. Memorial Sloan-Kettering Cancer Center in Manhattan changed its practice in September, because doctors knew the study results before they were published. But more widespread change may take time, experts say, because the belief in removing nodes is so deeply ingrained.
“This is such a radical change in thought that it’s been hard for many people to get their heads around it,” said Dr. Monica Morrow, chief of the breast service at Sloan-Kettering and an author of the study, which is being published Wednesday in The Journal of the American Medical Association. The National Cancer Institute paid for the study.
This again begs my initial question -- why did this "radical change" take 100 years to publicly disseminate.
Doctors and patients alike find it easy to accept more cancer treatment on the basis of a study, Dr. Morrow said, but get scared when the data favor less treatment.
The new findings are part of a trend to move away from radical surgery for breast cancer. Rates of mastectomy, removal of the whole breast, began declining in the 1980s after studies found that for many patients, survival rates after lumpectomy and radiation were just as good as those after mastectomy.
The trend reflects an evolving understanding of breast cancer. In decades past, there was a belief that surgery could “get it all” — eradicate the cancer before it could spread to organs and bones. But research has found that breast cancer can begin to spread early, even when tumors are small, leaving microscopic traces of the disease after surgery.
|Sentinel node biopsy incision|
The modern approach is to cut out obvious tumors — because lumps big enough to detect may be too dense for drugs and radiation to destroy — and to use radiation and chemotherapy to wipe out microscopic disease in other places.
Modern? Cut, slash and burn has been the protocol for over 50+ years.
But doctors have continued to think that even microscopic disease in the lymph nodes should be cut out to improve the odds of survival. And until recently, they counted cancerous lymph nodes to gauge the severity of the disease and choose chemotherapy. But now the number is not so often used to determine drug treatment, doctors say. What matters more is whether the disease has reached any nodes at all. If any are positive, the disease could become deadly. Chemotherapy is recommended, and the drugs are the same, no matter how many nodes are involved.
This latter sentence is frightening. Not because it causes me to reflect on my choice not to undergo adjuvant treatment. But because it is these types of statements that were used to try and bully me into acquiescing to chemo and radiation -- despite the undisputed medical conclusion that I would not benefit from chemo. It is these types of statements that plant fear into persons dealing with breast cancer and emotionally and mentally inhibits them from becoming informed patients.
|Injection of the the radioactive material|
in prep for the node biopsy
"...and the drugs are the same, no matter how many nodes are involved." This admission also sends chills down my spine. It should be a big ol' red flag that in light of it taking the med-pros 100 years to publicly declare this "nodal" revelation, that the med-pros are still unwilling, as a community, to reveal that the "standard protocol" for treating breast cancer reached a plateau decades ago. Refer back to my "audience with the Great Oz back in September, 2009."
The new results do not apply to all patients, only to women whose disease and treatment meet the criteria in the study.
The study, at 115 medical centers, included 891 patients. Their median age was in the mid-50s, and they were followed for a median of 6.3 years.
After the initial node biopsy, the women were assigned at random to have 10 or more additional nodes removed, or to leave the nodes alone. In 27 percent of the women who had additional nodes removed, those nodes were cancerous. But over time, the two groups had no difference in survival: more than 90 percent survived at least five years. Recurrence rates in the armpit were also similar, less than 1 percent. If breast cancer is going to recur under the arm, it tends to do so early, so the follow-up period was long enough, the researchers said.
One potential weakness in the study is that there was not complete follow-up information on 166 women, about equal numbers from each group. The researchers said that did not affect the results. A statistician who was not part of the study said the missing information should have been discussed further, but probably did not have an important impact.
It is not known whether the findings also apply to women who do not have radiation and chemotherapy, or to those who have only part of the breast irradiated. Nor is it known whether the findings could be applied to other types of cancer.
The results mean that women like those in the study will still have to have at least one lymph node removed, to look for cancer and decide whether they will need more treatment. But taking out just one or a few nodes should be enough.
Dr. Armando E. Giuliano, the lead author of the study and the chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health Center in Santa Monica, Calif., said: “It shouldn’t come as a big surprise, but it will. It’s hard for us as surgeons and medical oncologists and radiation oncologists to accept that you don’t have to remove the nodes in the armpit.”
Dr. Grant W. Carlson, a professor of surgery at the Winship Cancer Institute at Emory University, and the author of an editorial accompanying the study, said that by routinely taking out many nodes, “I have a feeling we’ve been doing a lot of harm.”
Indeed, women in the study who had the nodes taken out were far more likely (70 percent versus 25 percent) to have complications like infections, abnormal sensations and fluid collecting in the armpit. They were also more likely to have lymphedema.
I can attest to the abnormal sensations (euphemism for pain), that continue each and every day, to this day, since the SNB and mastectomy in August 2009.
But Dr. Carlson said that some of his colleagues, even after hearing the new study results, still thought the nodes should be removed.
“The dogma is strong,” he said. “It’s a little frustrating.”
This understated sentiment can be broadly applied in all aspects of the breast cancer industry.
Eventually, he said, genetic testing of breast tumors might be enough to determine the need for treatment, and eliminate the need for many node biopsies.
|BRCA Genes I & II Mutation|
Two other breast surgeons not involved with the study said they would take it seriously.
Dr. Elisa R. Port, the chief of breast surgery at Mount Sinai Medical Center in Manhattan, said: “It’s a big deal in the world of breast cancer. It’s definitely practice-changing.”
Dr. Alison Estabrook, the chief of the comprehensive breast center at St. Luke’s-Roosevelt hospital in New York said surgeons had long been awaiting the results.
“In the past, surgeons thought our role was to get out all the cancer,” Dr. Estabrook said. “Now he’s saying we don’t really have to do that.”
But both Dr. Estabrook and Dr. Port said they would still have to make judgment calls during surgery and remove lymph nodes that looked or felt suspicious.
The new research grew out of efforts in the 1990s to minimize lymph node surgery in the armpit, called axillary dissection. Surgeons developed a technique called sentinel node biopsy, in which they injected a dye into the breast and then removed just one or a few nodes that the dye reached first, on the theory that if the tumor was spreading, cancer cells would show up in those nodes. If there was no cancer, no more nodes were taken. But if there were cancer cells, the surgeon would cut out more nodes.
Although the technique spared many women, many others with positive nodes still had extensive cutting in the armpit, and suffered from side effects.
|A lymphedema patient, without |
the medical sleeve
After armpit surgery, 20 percent to 30 percent of women develop lymphedema, Dr. Port said, and radiation may increase the rate to 40 percent to 50 percent. Physical therapy can help, but there is no cure.
The complications — and the fact that there was no proof that removing the nodes prolonged survival — inspired Dr. Giuliano to compare women with and without axillary dissection. Some doctors objected. They were so sure cancerous nodes had to come out that they said the study was unethical and would endanger women.
“Some prominent institutions wouldn’t even take part in it,” Dr. Giuliano said, though he declined to name them. “They’re very supportive now. We don’t want to hurt their feelings. They’ve seen the light.”