Breast Cancer Surgery: Less Is Better? Review of the Study From JAMA By Ramesh T Kumar

Thursday, March 10, 20110 comments

46b6d34989 Breast Cancer Surgery: Less Is Better? Review of the Study From JAMA
By Ramesh T Kumar
Traditionally, early stage breast cancer patients have chosen to undergo breast conservation procedures. This involves at least three steps:
Step 1: The surgeon removes the lump from the breast
Step 2: The surgeon performs a dye injection into the lumpectomy area where the original cancer was located which tracks along lymphatic channels into lymph glands in the arm pit. This dye gets trapped in the lymph glands that drains this lumpectomy area and are called sentinel lymph nodes. Examination of these nodes may show cancer cells indicating that the breast cancer has spread. If these are negative then the surgeon believes that the breast cancer has not spread to these glands and no further surgery in the arm pit need to be performed.
Step 3. If the sentinel nodes showed cancer cells, the belief was that there were cancers spread to other nodes in the arm pit and needed to be removed. This procedure called lymph node dissection removed several nodes and sent to pathology for a full assessment as to the exact number of lymph nodes involved with cancer.
Step 4: The patient would receive external beam radiation therapy, also called Tele-therapy to the involved breast for a six to seven week period.

Step 5: Some patients would require chemotherapy based on various factors to make sure that the cancers do not come back elsewhere in the body.
So what was wrong with this picture?
As seen in step 3, the belief that all patients with sentinel nodes that contained cancer need to proceed to a complete lymph node dissection is the question that was asked in this study. The results showed that as long as these patients had minimum involvement of the nodes and were treated with external radiation therapy, that there really was no need to go through with complete node dissection. The problem was that lymph node dissection caused a significant risk of lymph-edema of the arm on that side which could be disabling and debilitating. The study authors found no difference in outcomes between the groups of patients who had sentinel node involvement with cancer whether they underwent lymph node dissection or not. Those who did not go through the full axillary node dissection had none of the complications such as lymph-edema while not compromising their ability to survive their cancer.
Which patients with early stage breast cancer who have cancer spread to the sentinel lymph nodes absolutely need to undergo full node dissection?
Those patients undergoing mastectomy, those undergoing lumpectomy without radiotherapy, those treated with partial breast irradiation, those receiving chemotherapy prior to surgery and those receiving whole-breast irradiation in the prone position, in which the low axilla is not treated.
In Summary: Axillary lymph node dissection may no longer be justified for women who have early stage breast cancer with minimal spread to the sentinel lymph nodes and who are treated with breast-conserving surgery, whole-breast irradiation, and some of chemotherapy.
Dr. Kumar is a board certified Radiation Oncologist who is co-founder of a private practice group called Coastal Cyberknife and Radiation Oncology in Saint Lucie County, Florida. He has over 17 years experience dealing with breast cancer patients including several members in his own family who have been afflicted by this disease.
His philosophy of managing patients is through a unique holistic approach that takes into account the wishes and needs of patients and their families. Education in simple language allows the patients to make the right decision when it comes to their cancer care. He believes that any battle is won at the level of the mind first before the body goes into action to win the war. His website reflects this philosophy. He is always available to help any patient with questions regarding cancer and radiation therapy and can be reached at 772 293 0377.
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