A medical study published this month promised good news for thousands of women whose breast cancer surgery might lead to a painful condition known as lymphedema.
This drastic and persistent arm swelling is a frequent consequence not of breast surgery itself, but of removing nearby lymph nodes.
But it turns out that the women in the study who kept their nodes, even if cancer was present, fared just as well as those who had them removed.
Still, will doctors and patients knowingly leave behind anything cancerous, even just a lymph node or two?
It will be a tough sell, admits Dr. Peter Blumencranz, director of Morton Plant Hospital's Comprehensive Breast Care Center and a co-author of the study, published in the Journal of the American Medical Association. Leaving behind lymph nodes known to have cancer goes against physician training and most current medical guidelines.
"We had trouble recruiting patients for the study because surgeons were uncomfortable with the idea of not taking the nodes," he said. Researchers hoped to enroll 1,900 patients, but only about half that number signed up.
"What we were asking them to do was radical," he said.
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For decades, doctors removed all lymph nodes from all breast cancer patients. Later, researchers found that only women with positive sentinel nodes (the first nodes where breast cancer typically spreads) had to have all their nodes removed. Then in 1999, a group of physicians, including Blumencranz, launched a study to find out if breast cancer patients with positive sentinel lymph nodes could be spared complete node removal.
The thought was that radiation and chemotherapy would eradicate stray cancer cells in the lymph nodes. "The good news is, after six years of followup, those women who kept their nodes did as well as those who had their other nodes removed," Blumencranz said.
Dr. Christine Laronga, program leader of the Don and Erika Wallace Comprehensive Breast Program at the H. Lee Moffitt Cancer Center in Tampa, helped recruit patients and remembers the early days of the study. "When doctors first heard about this study, everybody thought, are you crazy?" she said.
But as results started trickling in and there was virtually no difference in outcomes, Laronga and other practitioners started offering select patients the option.
When the study made national headlines, "all the women we saw wanted to be considered for not having their lymph nodes out," she said.
Only certain patients are considered eligible for the node-sparing approach: those who have early-stage breast cancer and are treated with lumpectomy, chemotherapy and whole breast radiation.
Dr. Suzanne Lynn, a breast surgeon at St. Joseph's Women's Hospital in Tampa, is bracing for disappointed patients. "They come in so hopeful; you hate to burst their bubble, but this doesn't apply to everyone," she says. Patients who opt for a mastectomy or for partial breast radiation were not included in the study, and may still be counseled to have their lymph nodes removed.
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Despite the research findings and the lowered risk of lymphedema, some patients still opt for node removal. Blumencranz said many women dropped out of the study when they found out their nodes were positive. "They were just uncomfortable with leaving any cancer behind," he said.
Cheri Wetzel, 62, of Sun City Center, understands those women. She was diagnosed with breast cancer in 2008 and had a lumpectomy. Three sentinel nodes were positive for cancer. A patient of Laronga, Wetzel wanted the nodes out then and says she would make the same decision today — even though she has suffered from lymphedema (see box).
"Leaving lymph nodes behind, where you know there are cancer cells, no," Wetzel said. "I feel more comfortable that it's been removed."
Will this study change medical treatment guidelines?
Experts say yes, but it may take time to win over skeptical physicians and patients.
"Some will be very happy to know they can keep their nodes," Lynn said. "Others will still have the fear of leaving cancer behind. At least now we can let them know what the facts are."
Irene Maher can be reached at firstname.lastname@example.org