Lymph Node Removal May Be Avoidable in Some With Breast Cancer

Patients with DCIS who are aged 70 and older may not need to remove their lymph nodes during treatment.

Among patients with breast cancer, the majority of older patients with estrogen receptor (ER)-positive ductal carcinoma in situ who are undergoing mastectomy (surgical removal of all or part of the breast) do not need to have their lymph nodes removed, researchers have found.

“Patients have the opportunity, with this study and some others that are similar to it, to really sort of question the degree to which they need to be to throw the kitchen sink at their disease when we know that it's probably going to be a fairly indolent disease that is probably not going to be what causes their ultimate mortality,” Dr. Austin D. Williams said during an interview with CURE®.

Williams is an assistant professor in the Division of Breast Surgery at Fox Chase Cancer Center in Philadelphia.

DCIS, according to the American Cancer Society, is a non- or pre-invasive breast cancer, also known as stage 0 breast cancer, and accounts for approximately 20% of all new breast cancers.

Williams and his colleagues, who published their findings in the Annals of Surgical Oncology, drew on the data of 9,030 patients aged 70 and older with DCIS undergoing mastectomy who also received axillary surgery. Axillary surgery, according to the National Cancer Institute, is a surgery to remove lymph nodes found in the armpit region.

Under the guidelines of the Choosing Wisely initiative from the American Board of Internal Medicine, Williams and his fellow researchers found that 93% of the entire cohort and 97% of patients with ER-positive DCIS could have avoided axillary surgery.

“Surgeons are currently overusing axillary surgery in patients [at least] 70 years [old] undergoing mastectomy for DCIS,” researchers wrote in the study. “We can choose more wisely by omitting axillary surgery in this patient population, particularly for patients with low-risk features such as ER positivity and low tumor grade, and we recommend routine omission of axillary surgery for these patients.”

“There's an option in sort of this gray area for patients who meet these criteria to avoid lymph node surgery,” Williams told CURE® in the interview. “You know, we've been getting away from a lot of axillary dissections, removal of all of the lymph nodes, and that has decreased our rates of lymphedema (swelling due to a buildup of lymph fluid, typically in the arms and legs).

“But, doing a sentinel node biopsy remains standard in many cases, but is also associated with pain and a small risk of lymphedema and those sorts of things. So, patients can feel as though they have an option to potentially avoid that portion of the surgery.”

A sentinel lymph node biopsy, according to the National Cancer Institute, involves the removal of the first lymph node where cancer has most likely spread from a primary tumor, and can sometimes involve multiple lymph nodes.

Williams discussed the importance of avoiding lymph node removal if possible.

“The predominant issue whenever we're removing lymph nodes is the concern for lymphedema,” he said. “And while when we remove all of the lymph nodes, the axillary dissection, that rate is about 30%, it's only about 4% from a sentinel node biopsy. However, it is a separate incision, an incision that can cause pain postoperatively and even some long-term nerve pain and these sorts of things.

“So, if we aren't going to find anything, if we're not going to use the information that we find, you know that morbidity from a lymph node removal perspective, I would say that the risk then outweighs the benefit of that portion of the surgery.”

As options increase, Williams said, approaches to care become less and less cookie-cutter, as he explained.

“Surgeons can discuss with patients, can discuss with the medical and radiation oncologist, what information we actually need in order to make treatment decisions for a specific patient,” Williams said. “If we were to do, for example, the lymph node portion of the surgery, would that information actually change what the medical oncologist would recommend, or what the radiation oncologist would recommend?

“And so for each patient, especially in this group, 70 and older — which, one of the arguments is that 70 is the new 50 so we don't call these patients elderly by any means, but at the same time, you know that they're probably not benefiting from some of these things, and so we really need to think about our recommendations, talk to the patient about their desires, and also sort of look holistically ... at the patient [and ask] what medical problems do they have, and what are their ultimate goals as it relates to their treatment, to come up with a better plan for that specific patient.”

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