Lymph Node Removal Is Overdone In US

Surgeons may be performing unnecessary axillary lymph node dissection (ALND) on women who will not benefit from it, studies show. The surgery often leads to lymphedema, and doesn’t improve survival rates or reduce the risk of recurrence in a subset of cancer patients.

During the course of a breast cancer diagnosis, a patient’s lymph nodes are checked to see if they’re cancerous. A sentinel lymph node biopsy (SLNB) is a biopsy of the lymph nodes closest to where the cancer is in the breast, and is usually done at the same time as tumor removal. An axillary lymph node dissection (ALND) removes an average of 10–20 lymph nodes in the armpit area to check for cancerous cells. Doing a biopsy of those nodes can help determine the stage of breast cancer and the best course of treatment.

Photo: Adobe Stock/likoper
Photo: Adobe Stock/likoper

Lymphedema is a possible side effect of cancer treatment, including breast cancer surgeries, lymph node removal, and radiation — and it’s a side effect that cancer patients fear a great deal. Lymphedema occurs when lymph fluid collects in bodily tissues rather than being drained by lymph nodes. This causes swelling, typically of the arm, hand, chest wall, or back. Restricted movement of the arm and shoulder is also a potential side effect.

About 5% of women who get a sentinel node biopsy will develop lymphedema, while about 20% of those who get an ALND will develop lymphedema.

Despite the similarity in survival rates and risk of recurrence, and the additional risk of lymphedema, surgeons are still performing ALNDs on patients who simply don’t need them.

Photo: AdobeStock/maya2008
Photo: AdobeStock/maya2008

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A study published in JAMA in 2017 titled Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis looked at 891 women who were diagnosed with breast cancer over a 13-year span, between May of 1991 and December of 2004. All of the women had early-stage breast cancer that wasn’t considered aggressive and had no suspicious lymph nodes. They underwent a lumpectomy, a sentinel lymph node dissection that showed either one or two of the nodes positive for cancer, and radiation of the entire breast. In addition, most of the women underwent chemo or hormone therapy, or both, after surgery.

These women were then split into two groups; one group had axillary lymph node dissection, and the other had no further surgery.

Follow-up done after 5 years and after 10 years showed no statistical difference in survival rates. They found 86.3% of the women who had SLNB survived, and 83.6% of the women who had ALND survived. When it came to recurrence rates, the results were still very similar: 80.2% of the women who SLNB had no recurrence, and 78.2% of the women who had ALND had no recurrence.

It’s important to note that the results of the study does not apply to women who got a mastectomy or had suspicious lymph nodes prior to the dissections.

Photo: Adobe Stock/lyosha_nazarenko
Photo: Adobe Stock/lyosha_nazarenko

A study published in JAMA in July of 2018 titled Surgeon Attitudes Toward the Omission of Axillary Dissection in Early Breast Cancer found that about half of the surgeons surveyed would perform an ALND even though the most recent studies show they are unnecessary.

488 surgeons were invited to participate in the survey, and 376 actually did. The survey found that 49% of the surgeons would “definitely” or “probably” recommend ALND if one sentinel node was found to be cancerous, and 62.6% would “definitely” or “probably” recommend it if two sentinel nodes were found to be cancerous.

Surgeons who performed the most surgeries were the most willing to forgo ALND, while surgeons who were in surgery far less opted to recommend the procedure.

Photo: Adobe Stock/michaelheim
Photo: Adobe Stock/michaelheim

Surgeons are often late in moving forward with changes to standard practice, Dr. Sara Javid and Dr. Benjamin Anderson pointed out in an editorial attached to the study. One way to push them towards adopting these changes in procedure more quickly is to give them access to their performance in relation to the performance of their peers.

“With increased visibility of one’s own performance relative to peers and evidence-based standards of practice, combined with the support of a respected credentialing body, such as the American Board of Surgery, toward the delivery and measurement of care, meaningful change is plausible,” Javid and Anderson stated.

Surgeons need to be held accountable for causing patients unnecessary harm. If your doctor is recommending an axillary lymph node dissection and you don’t understand why you need one, ask for clarification and always get a second opinion.

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