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Researchers cast doubt on need to excise cancerous lymph nodes

By Denise Grady
New York Times / February 9, 2011

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NEW YORK — A new study finds 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.

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 returning.

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 can be disabling.

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.

Specialists say 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 New York changed its practice in September, because doctors knew the study results before they were published. But more widespread change may take time, specialists 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 being published today in The Journal of the American Medical Association.

The National Cancer Institute paid for the study.

Morrow said doctors and patients alike found it easy to accept more cancer treatment on the basis of a study — but got scared when the data favored 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.

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.

Dr. Armando 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.’’

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