Less Traumatic Surgery for Some Breast Cancers?

Here’s the backstory: Up to now about 20 percent of breast cancer patients – those found to have cancer in the lymph nodes under their armpits – had those nodes cut out as if they were little balloons that could carry metastases to anywhere in the body. And indeed, sometimes cancer spreads via the lymph nodes, which is why they had to go. Or so thought any responsible oncologist.

For the women who undergo extensive axillary dissection (that is, cutting under the arms and removing the nodes), the risk of complications goes up. They are more vulnerable to infection, but more importantly, many of them get lymphedema – painful, chronic swelling of the affected arm due to the inability of the lymphatic system to remove excess fluid from the limb. It’s miserable, disabling, and disfiguring. It can be progressive. It has no cure. You don’t want to have it. Women can also suffer nerve damage, shoulder pain, and limited mobility of the arm. (All of this goes for male breast cancer patients, too.)

But the medical thinking was: We need to cut out any microscopic cancers to minimize the risk of recurrence. What patient would risk her life to buck that logic?

Now, the sun has set on this thinking. A major new study has proven that for properly selected patients – those with tumors smaller than two inches whose cancer has spread to the nodes – axillary dissection and all of its attendant ills is not necessary. It confers no survival advantage. None! Chemo and radiation – which are de rigeur for anyone with nodal cancer – seem to work equally well if the nodes are left in peace. I have not looked at the study, but what I read in the New York Times was highly persuasive and well reported. (Were I the patient, I’d definitely want to scour the scientists’ original article.)

The new recommendation is irrelevant to most early-stage patients, whose disease has not yet spread to the nodes (which can be ascertained by examining a couple of likely suspects with “sentinel node biopsy”). Nor will it help those people diagnosed with more advanced disease. None of the patients in these two groups should be treated with axillary dissection anyway, under normal circumstances. But boy, it could make life after cancer a whole lot more comfortable for the folks who fall in that 20% – for whom lymphedema often became a painful lifelong reminder that they’d had cancer and it could recur at any time.

Will doctors actually take the study’s findings to heart? That’s where I’m skeptical. Axillary node dissection just met its Waterloo. But will breast surgeons – indoctrinated by education that says more treatment is better, and anything less is irresponsible – continue to fight the old battle? I’m afraid they will, and not just because I cynically think they fear lawsuits. (Any sentient doctor should fear lawsuits; they’re part of the landscape by now.) No, I worry that habit will prevail, along with the conviction that doing something is always better than doing nothing. The New York Times report that major cancer centers and a few individual doctors are changing their protocol:

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.”

Patients may need to push their doctors. We can ask them about our options. If they’re unwilling to question from old methods, we can find another doctor. I’m not in that position right now (thank my stars), but I’ve had multiple scary mammograms. If I do get cancer, I’d hope for an aftermath where my body wouldn’t bear more scars than necessary.

The rage expressed in the NYT comments section by women who live with those reminders – unnecessarily, they now know – is justified, even though their physicians did the best they could with the knowledge they had. But now that we know more? I wouldn’t want to live with that pain and rage if it could be avoided. Life after cancer poses enough other challenges.