Early-Stage Breast Cancer: Should You Really Remove Your Nodes?
For years, removing numerous lymph nodes in the armpit and surrounding breast tissue was a common approach to reduce cancer spread in early-stage breast cancer patients. However, new findings reveal that this extensive procedure may not always be necessary.
A growing body of research challenges the need for aggressive lymph node removal, suggesting a more conservative approach could be equally effective — with fewer long-term complications. At the 2023 San Antonio Breast Cancer Symposium (SABCS), researchers presented compelling evidence: women with early-stage breast cancer who underwent limited lymph node surgery, removing only the “sentinel” nodes, were less likely to experience recurrence or die from their illness. This conclusion, drawn from 29 clinical trials involving over 20,000 women, also showed that a more conservative surgery reduced the risk of lymphedema, a painful fluid buildup that can occur post-surgery.
Sentinel Lymph Node Biopsy vs. Axillary Lymph Node Dissection
One landmark study, published in JAMA, examined two groups of women with early-stage breast cancer treated with lumpectomy and follow-up therapies, like radiation. Half of the participants had only a sentinel lymph node biopsy — the removal of a few key nodes from the underarm area. The other half underwent an axillary lymph node dissection, a more extensive procedure involving the removal of multiple nodes. The result? After a decade of follow-up, recurrence rates and survival rates between the two groups were strikingly similar.
In most early-stage cases, cancer is still contained within the breast or nearby lymph nodes in the axilla, often the sentinel nodes. The sentinel node biopsy, involving the removal of one to three nodes, helps doctors assess whether cancer has spread. As Dr. Armando Giuliano, a leading oncologist and pioneer in sentinel node research at Cedars-Sinai Medical Center, explains: “The sentinel node is the first place cancer cells would travel if they spread at all. We’ve found that if the sentinel node is negative, cancer has almost certainly not spread elsewhere.”
What If Cancer Is Found in the Sentinel Node?
Even when cancer cells are detected in a sentinel node, the necessity of further node removal remains unclear. Historically, surgeons often performed a complete axillary node dissection, hoping to prevent cancer cells from lurking in undetected nodes.
This early assumption faced skepticism, however, with some experts concerned that initial studies weren’t extensive enough. However long-term data from follow-up studies reinforced the original findings: even for patients with cancer-positive sentinel nodes, further node removal didn’t significantly improve outcomes.
The Risks of Extensive Node Removal: Lymphedema and Beyond
The difference between a sentinel lymph node biopsy and a full axillary lymph node dissection is more than just a matter of surgical scope; it’s about preserving patients’ quality of life. Removing multiple lymph nodes can have a profound impact. Lymph nodes help circulate lymph, a fluid crucial to immune function. Without these nodes, fluid can build up in the arm, causing lymphedema — a condition that often leads to swelling, discomfort, reduced mobility, and sometimes chronic pain. “Lymphedema can severely impact a patient’s life, with swelling that limits movement and causes persistent pain,” Giuliano explains.
Understandably, some patients may feel anxious about leaving any nodes behind, especially if cancer is found in even a single sentinel node. However, oncologists emphasize that most early-stage patients will also undergo radiation therapy, which can target residual cancer cells in the lymph nodes. Other treatments like chemotherapy, hormone therapy, or targeted therapy can also destroy cancer cells in the nodes.
What About Other Breast Cancer Cases?
It’s important to note that these findings specifically apply to patients with early-stage breast cancer who opt for lumpectomy followed by additional treatments, like radiation and chemotherapy. Questions remain about whether patients with other forms of breast cancer might also benefit from a less invasive approach. As Dr. Giuliano highlights, “Our primary focus now is on understanding the role of chemotherapy’s impact on lymph nodes prior to surgery. It’s essential to determine whether additional node removal is necessary after pre-surgical treatment.”
Moving Forward: Discussing Options with Your Doctor
For patients facing early-stage breast cancer, the decision to remove lymph nodes is no longer one-size-fits-all. If lymph node removal is recommended, consider discussing the option of a sentinel node biopsy with your healthcare team, especially if you’ll also be undergoing additional therapies. If extensive node removal seems unavoidable, Dr. Giuliano suggests seeking a second opinion.
For many women with early-stage breast cancer, extensive lymph node removal isn’t a requirement for a positive prognosis. Emerging research shows that removing just a few nodes offers similar recurrence and survival rates compared to removing more nodes — and may help preserve long-term quality of life. With additional therapies like chemotherapy, hormone therapy, and targeted therapy already attacking any cancerous cells in the nodes, the more conservative approach may often be the wisest one.