NPR STORY ON AXILLARY LYMPH NODES IN EARLY BREAST CANCER
Aired on May 6, 1999

by Diane Toomey, WUNC Radio, UNC-Chapel Hill

When a patient is diagnosed with breast cancer, it's often been standard practice to remove the lymph nodes under that patient's arm in order to test for spread of the cancer. But that operation can have serious and lasting effects. Two recent studies out of local universities deal with the issue of lymph node removal. One questions the *need* for this invasive procedure and the other offers an alternative. WUNC's Diane Toomey reports.

Whether a breast cancer patient's lymph nodes test positive or negative for spread of the disease often determines what type of treatment a women will undergo following surgery. For instance, will she have tamoxifen or chemotherapy. But for some women, like those with advanced breast cancers, nodal information isn't critical because they're going to receive chemotherapy and radiation anyway. And many older women aren't realistic candidates for chemotherapy, so again, axillary, or underarm node status wouldn't determine treatment. But duke university statistician Giovanni Parmigiani looked at data on patients diagnosed with early stage breast cancer, women who are going to have a lumpectomy followed by radiation.

"the axillary lymph nodes are not taken out as part of the routine surgical procedure and one has to decide to have that as an additional procedure in the case we're analyzing."

But information gleaned from removal of most of a patients underarm lymph nodes can come at a price. Some women are left with serious after-effects, including pain, decreased range of motion, numbness and *severe* swelling. and these conditions can be permanent. But nodal status has been used as a guide to determine post-surgical treatment in breast cancer. Women with certain types of tumors can be given the drug tamoxifen, but if cancer has spread to the lymph nodes, chemotherapy would also be given.

"this is where the main changes in our understanding of the efficacy of therapy have been in the last three years. bec. the results of clin. trials have shown the advantages of chemo therapy over tamoxifen do not seem to depend as strongly as we once believed on whether there has been spread to the lymph nodes. ... and so it's been less common to make the decision of tamox. versus chemotherapy based on lymph node involvement."

Another factor in deciding whether or not to remove the axillary lymph nodes is the likelihood they'll actually *be* cancerous. For instance, take the case of a woman with what's considered to be a small tumor.

"if the lymph nodes don't show in a clinical exam any evidence of spread of the disease, that is if no cancer can be felt, then the probability f this women has no spread at all shown in the surgical procedure is about 84 percent. so about 84 percent will come out to be negative after the surgical procedure."

So the great majority of patients in this case will gain nothing from the procedure. And what about the approximately 16% of patients whose lymph nodes *are* cancerous? If they don't know that, and are treated with tamoxifen only, their prognosis, Parmigiani says differs only slightly from those who know their nodes are cancerous and receive chemotherapy as a result. Parmigiani admits this topic is a controversial one, in part because some physicians now believe not all types of chemotherapy are created equal. oncology surgeon Kelly mcmasters, at the university of Louisville, is one them.

"we're not just giving the same chemo to all women anymore. based upon recent results that were released last year, many are now using adreomyicin cytoxin plus taxol. that means more aggressive chemo, more toxic chemo regimens given to more women. and the decision to use that more aggres. chemo is based upon the finding and the number of positive lymph nodes."

but there's a relatively new operation to determine whether cancer has spread to the lymph nodes and the procedure may provide answers without the risk of side effects. doctor David ollila performs sentinel node biopsy, as it's known, at UNC. Using both blue dye and a radioactive marker, the oncology surgeon traces the path a cancer cells would have taken had they migrated out of the breast.

"you inject a radioactive tracer and a blue dye and what that does, when you inject around the tumor, it's taken up and it goes to the first draining lymph node, and that lymph mode would be the first one to receive metastatic tumor if it has occurred. so if you take out that node and it has tumor in it, then you know you need to take out the rest of the lymph nodes."

more and more women are asking for this less invasive procedure, but ollila cautions that it must be done by a surgeon experienced in the technique.

"you can't go to a course, see one person do a couple, you do a couple on an animal model and you go back and think you're going to be able to do it. there are nuances to it from the most basic of where and how to inject the dye and radioactive tracer to compression of the breast to where to make the incision to maximize the chances of finding the sentinel node."

Ollila says hospitals should do validation trials before they routinely offer sentinel node biopsies. This involves performing the sentinel procedure on a significant number of women followed, as a check, by complete lymph system removal. UNC's validation study, which looked at 65 patients, had no false negatives. that is, in every case where researchers determined the lymph system to be cancer-free, based on the sentinel node, that result held up when the remaining underarm lymph system were removed and examined. ollila says women considering the procedure should ask their doctor two questions.

"how many of these have you done and how many times have you've wrong"

That's what Deborah asked when she was weighing her options. Deborah, not her real name, traveled from out the area to have her sentinel node biopsy done at UNC. but not before she did a lot of research.

"they give you a lot of literature in the doc's office but there's nothing about this.so I read medical journals and a lot of the articles were written as long as a year ago. and as time progressed they became more recent and more definite about how effective it would be. a lot of them said we still don't know enough, so by the time I got to chapel hill I understood perfectly what it was all about."

Deborah understands there's a small chance that her sentinel procedure will result in a false negative, but she says she's comfortable with the her surgeon's track record.

"I'm pretty active and I like to do a lot of things and I'd heard enough about the complications from having all the lymph. nodes out that I decided to take the chance."

University of Louisville's Kelly Mcmasters also performs sentinel node biopsies and has written about the procedure in the new England journal of medicine. he says some hospitals where the procedure is done have overall false negative rates as high as 18 percent.

"that's too high. ... less then 5 percent is certainly a goal we would like to strive for. most of the studies have shown rates betw. 5 and 12 percent. I think we need to decide when a less invasive proc. is worth the risk of having a false neg. how many women will be harmed vs. how many will be helped by having a less invasive. procedure."

both Mcmasters and UNC's David ollila point out that sentinel node biopsy, if done properly, can be much more accurate than the conventional method. because the pathologist is handed just one node, as opposed to about 20, a much more thorough exam can be done on it. As a result, micrometatastic cancers, which wouldn't have been detected otherwise, can now be found. its estimated that the sentinel node procedure will identify about ten percent more patients with positive nodes then was possible with full lymph system removal.

For WUNC Radio, I'm Diane Toomey