Less radical breast cancer treatment could become norm

How physicians approach treating breast cancer is likely to change because of a new study examining the benefits, or lack thereof, of radical surgery to remove lymph nodes near the tumor, experts said. But they're not sure how quickly it will change.

A study in the Feb. 9 Journal of the American Medical Association found no difference in survival rates for patients who had axillary lymph node dissection and those who had sentinel lymph node dissection.

"This study and others like it may ultimately change the standard for breast surgery among women with breast cancer who have sentinel nodes that test positive for the disease," said Otis W. Brawley, MD, chief medical and scientific officer of the American Cancer Society.

The findings may lead to less harmful cancer treatments, he said. Axillary lymph node dissection often causes side effects such as lymphedema, infection and limited shoulder and arm movement.

The study is the latest in a growing body of research indicating the benefits of less radical cancer surgery when combined with systemic treatments such as chemotherapy, said Grant Walter Carlson, MD, a surgical oncologist at Emory University Hospital in Atlanta. But how quickly researchers' findings will translate into changes in routine treatment is a matter of debate.

Clinical practice changes often are slow, said Armando Giuliano, MD, lead author of the JAMA study and chief of medicine and science at John Wayne Cancer Institute at St. John's Health Center in Santa Monica, Calif. "Everyone's reluctant to abandon the old and adopt the new. It's hard to think that less radical treatment may be better."

Researchers for the JAMA study followed 891 early-stage breast cancer patients with no palpable swollen lymph nodes around the tumor but who had one or two lymph nodes draining directly from the tumor. Of those, 445 patients underwent axillary dissection in which a median of 17 lymph nodes were removed. An additional 446 patients had just the sentinel lymph nodes removed.

All patients also had lumpectomies, whole-breast irradiation and systemic treatment. Survival rates after five years were 91.8% for women who had axillary dissection and 92.5% for those who had sentinel dissection.

The study originally was designed to follow 1,900 patients, but enrollment was stopped early because of the low mortality rates.

Despite the findings, some patients may resist getting the less radical surgery, said Elizabeth Steiner, MD, associate professor of family medicine and director of the breast cancer education program at Oregon Health & Science University Knight Cancer Institute in Portland. "You hear the word 'cancer,' and you want to do everything you can to get that sucker out of your body," she said.

Primary care physicians will be key in translating the findings from this and other studies. "It's really important for family physicians to play an ongoing role in counseling patients about breast cancer," Dr. Steiner said. "Our longstanding relationships with these women allow us the opportunity to really explain things to these women in a way they will understand."

Barriers to change

Breast cancer treatments have changed gradually in recent decades, Dr. Brawley said. Similar research more than 30 years ago showed the benefits of the lumpectomy over the radical mastectomy for most patients, but it took more than a decade for many surgeons to change.

"We tend to be very conservative, and we tend to be very set in our ways," he said.

If the study's findings ultimately are validated through other research and incorporated into standard practice, it would improve the quality of life for thousands of breast cancer survivors, he added.

Another barrier is that busy physicians have little time to read new research and determine how best to integrate findings into their practice, Dr. Steiner said.

But some believe change will occur more quickly, in part because patients will demand it. Most patients are reluctant to have the more radical surgery because of the potential for debilitating side effects, said Lynn Schuchter, MD, professor and chief of hematology and oncology at the University of Pennsylvania School of Medicine.

"I think the uptake of these results could happen quite rapidly, because women don't want the [axillary lymph node dissection] surgery," she said.