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‘Practice-Changing’ Cancer Study Shows Lymph Node Surgery May Be Unnecessary

February 9, 2011 at 7:01 PM EDT
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A decades-old treatment for breast cancer does not necessarily improve survival rates in women with early stage cancer, according to a study released this week. Gwen Ifill speaks with co-author Dr. Monica Morrow, a surgical oncologist at New York's Memorial Sloan-Kettering Cancer Center.

GWEN IFILL: And to the first of two health stories.

For decades, treatment for breast cancer has often included surgically removing lymph nodes from underneath a woman’s arm, where the disease might have spread. But a new study of 900 women finds that such invasive surgery does not necessarily improve survival rates in women with early stage cancer.

Dr. Monica Morrow is a co-author of the study and a surgical oncologist at Memorial Sloan-Kettering Cancer Center.

Welcome, Dr. Morrow.

DR. MONICA MORROW, Memorial Sloan-Kettering Cancer Center: Thank you.

GWEN IFILL: What did your studies show in the end that is different from the — what practice has been so far on this?

DR. MONICA MORROW: Well, what practice has been in recent years is that we do a sentinel node biopsy, that is, identify the first node where cancer cells would go if they had spread. And if that node in is normal, we don’t take out the lymph nodes.

But it has been standard practice, if there’s cancer in the sentinel node, to remove them. What our study showed was that in women who are having lumpectomy and radiation to the breast, that if you have cancer in just a few sentinel nodes, less than four, it’s not necessary to remove them, and you still have a very high rate of control of cancer under the arm, and it doesn’t influence survival, and it saves a lot of side effects.

GWEN IFILL: What — talk about the side effects. What’s the downside to just taking everything out to be on the safe side?

DR. MONICA MORROW: Well, the downside is that removing all those lymph nodes under the arm is associated with a lifetime risk of arm swelling or lymphedema, which is at least 20 percent. It also can cause numbness in the skin in the upper inner aspect of the arm. It can decrease the mobility of the arm and the ability to use the arm.

And it’s a bigger operation with a longer surgical recovery. So, if it doesn’t do any good, it’s not being safe. It’s just unnecessary side effects.

GWEN IFILL: So, how many women who are in this category you talk about, women who are candidates for a lumpectomy fairly early on, it has not spread to more than one or two nodes, how many women would be affected by this — this change in procedure?

DR. MONICA MORROW: It’s a little bit hard to say because of the way we collect data, but I would say somewhere between 15,000, as a low estimate, and 30,000 women a year could potentially be affected by this.

GWEN IFILL: Is it fair also to say that, if you are a candidate for a mastectomy, the full removal of the breast, that you are not a candidate for this kind of reduced approach?

DR. MONICA MORROW: Yes, that’s a very important point. We think part of the reason that this works is because, if you have a lumpectomy, you get radiation to your breast, which treats part of the lower armpit.

If you do a mastectomy, radiation is not routine, and it remains standard practice to remove involved lymph nodes in women who are having a mastectomy.

GWEN IFILL: The question many patients have about all cancers, but certainly with breast cancer, is the question of recurrence. So, if you take this approach, this more confined approach, targeted approach, is the likelihood of recurrence reduced?

DR. MONICA MORROW: The likelihood of recurrence isn’t reduced, but it’s also not increased.

And I think one of the really great pieces of news from this study was that, whether you have the lymph nodes removed or not, the risk of cancer recurring in your armpit is less than 1 percent. And with modern treatment, drug therapy, surgery and radiation, the risk of cancer recurring elsewhere in the body, at least for the first five years, is less than 10 percent, which is a remarkable improvement compared to say 20 years ago.

GWEN IFILL: You’re a practicing oncologist at Memorial Sloan-Kettering. How would this kind of finding affect the kind of work that you do?

DR. MONICA MORROW: Well, this has already changed our practice.

We consider this to be a practice-changing study. And so our entire group, the surgeons, the medical oncologists, the radiation oncologists, our pathologists, and breast imagers, got together after this study was presented in June and reviewed the literature, talked about the data, and as of September 2010, we stopped removing all the lymph nodes in women who meet the criteria for this study, namely small cancers, no abnormal lymph nodes to feel, and undergoing lumpectomy and breast radiation.

GWEN IFILL: And the reaction has been among patients?

DR. MONICA MORROW: Actually, the reaction among patients has been astonishingly positive.

Women are, obviously and appropriately, quite concerned about making sure that they treat their cancer in such a way as to minimize the risk that it will come back. But when we have presented this to women, because of the fear of arm swelling in particular is so great, at least in my practice, they have been uniformly accepting of this change, and actually think it’s a great thing.

GWEN IFILL: OK. So, that’s in your practice.

What about doctors who have been practicing the more invasive procedure as standard protocol, the way of doing business, all of these years, and now you come and say to them do it differently and do it less exhaustively, I suppose? Are doctors likely to embrace this new approach?

DR. MONICA MORROW: Well, you have to remember, if we could embrace it at Memorial Sloan-Kettering, which is one of the homes of aggressive cancer surgery, where we’ve been doing it for years, I suspect that other people can, too.

You know, change is always difficult, but we moved from doing radical mastectomies to doing lumpectomy and radiation to treat breast cancer with excellent results. And this is just part of that evolution. And I think it’s important for patients to understand it doesn’t mean they’re getting less treatment.

The cancer is being killed with radiation and with drug therapy, which allows us to use smaller surgery with fewer side effects. But I think it will take a while for physicians to change their practice. But now that the paper is out for everyone to review, it’s time for that change to begin.

GWEN IFILL: You talk about evolution and — and the move, for instance, from mastectomy to lumpectomy. Give us a better sense of that. Are we in the middle of a moment in which treatment in general is changing on breast cancer? Or is this a very discrete, specific breakthrough that is not going to really affect that many people?

DR. MONICA MORROW: No, I think we are in the midst of a very important and appropriate change in breast cancer therapy, which many people have described with the somewhat overused term “personalized medicine.”

So, we are moving from what we used to do, which was the same operation on every single woman with breast cancer, a mastectomy, to tailoring the amount of surgery in the breast to the amount of cancer that’s there. This study shows that you can tailor lymph node surgery in the same way.

And then we’re looking at drugs, not just giving everyone chemotherapy, for example, but selecting drugs that target specific aspects of the cancer, the HER2, for example, the estrogen receptor. And by putting these kinds of individualized therapies together, we’re getting better results.

GWEN IFILL: Dr. Monica Morrow, thank you for the good news. Nice talking to you.