Early Stage Breast Cancer: Do You Really Need Your Lymph Nodes Removed?

One of the most dreaded aspects of breast cancer surgery — removal of lymph nodes in the area surrounding the breast and in the armpit — is unnecessary for many women with early-stage breast cancer, according to new research.

A study published in September 2017 in the Journal of the American Medical Association followed women with early-stage breast cancer who were treated with a lumpectomy followed by radiation or other therapy to kill remaining cancer cells. Half of the women in the study had only a few lymph nodes removed (sentinel lymph node dissection) from under the underarm, while the other half had a large number of lymph nodes removed, a procedure known as axillary lymph node dissection. But after 10 years of follow-up, both groups had similar rates of disease recurrence and survival.

The study confirms the results of an earlier study published in the Journal of the American Medical Association.

The Question of What to Do About Lymph Nodes Has Been a Puzzle

Early-stage breast cancer is generally defined as disease that has not spread beyond the breast or the axillary lymph nodes. The majority of breast cancer patients in the United States are diagnosed with early-stage cancer.

Research pioneered by Armando Giuliano, MD, director of the 2017 trial and executive vice chair of surgical oncology at Cedars-Sinai Medical Center in Los Angeles, almost two decades ago revealed that breast cancer often first spreads to nearby lymph nodes called the sentinel nodes. Taking out and examining one to three sentinel nodes — called a sentinel lymph node biopsy — can help physicians assess the spread of cancer.

“The sentinel node is the first lymph node to which cancer will spread, if it spreads,” says Dr. Giuliano. “We’ve proven that if the sentinel node is negative (no cancer), 99 percent of the time the cancer has not spread elsewhere in the body.”

What if a sentinel node is positive?

But the question of whether surgeons needed to remove axillary nodes beyond the sentinel ones when a sentinel node is positive for cancer, remained unanswered. Doctors generally took out the axillary nodes as a precaution. “We expected that there would be other positive nodes, and you wouldn’t want to leave those behind,” says Giuliano.

While many doctors embraced the findings of the earlier study, others felt it was too short and had too few patients to draw firm conclusions. The new study followed the patients for 10 years and confirmed the original findings. “Now, after 10 years of follow-up, I think everyone is embracing this advice,” Giuliano says.

Women should be greatly reassured by this news, says Giuliano. “This study shows you don’t have to do it. Women are afraid of that operation. The operation is associated with side effects.”

Removing Lymph Nodes Is Not Without Consequences

Axillary lymph node removal, which typically involves removal of 15 to 25 nodes, can have troubling consequences. Lymph nodes carry fluid, called lymph, through regions of the body to help fight infection and remove toxins. When a large group of the tiny, round nodes is surgically removed, lymph fluid may be unable to flow freely. The buildup of fluid is called lymphedema.

“Some women get terrible arm swelling from lymphedema,” Giuliano says. “You can have shoulder problems, such as a limited range of motion, numbness, and pain that can be chronic and persist long-term. These problems are very difficult to manage.”

It may worry some women to leave the lymph nodes intact when cancer is found in one or two sentinel nodes. But, Giuliano points out, most patients with early-stage breast cancer also have radiation therapy, which kills cancer cells in the lymph nodes. Chemotherapy, hormone therapy, and targeted therapy — medication prescribed to some women based on the type of breast cancer they have — also destroys cancer in lymph nodes.

The study findings only apply to women with early-stage breast cancer who have lumpectomy and additional treatment, such as radiation and chemotherapy. More research is needed on whether other types of breast cancer patients can perhaps avoid axillary lymph node removal.

“The main question now concerns how to manage the axillary lymph nodes if a breast cancer patient has had chemotherapy before the operation,” Giuliano says. “What is the effect of chemotherapy on nodal involvement?”

But for now, women with early-stage breast cancer who choose lumpectomy followed by additional therapy should discuss the necessity of axillary lymph node removal with their doctors prior to surgery, he says. If axillary node removal is recommended, “Get a second opinion,” he says.