Axillary node dissection has been the standard of care for patients with breast cancer who have early metastatic disease as indicated by a positive axillary lymph node biopsy. In other words, an axillary lymph node is biopsied; if it contains cancer cells the axilla on the affected side is dissected and its lymph nodes are removed. A new study in the Journal of the American Medical Association indicates that this treatment conveys no benefit compared to women with the disease at the same stage who received conventional treatment without the axillary dissection.
This is being seen as an almost revolutionary finding among breast cancer surgeons. The New York Times has given the report an major article in its Health section. I have no doubt that the finding is correct – what is most newsworthy is that the futility of axillary node dissection has been blindingly obvious for decades. The history of breast cancer surgery is scarred with overly aggressive treatments that have been defended by surgeons almost to the death despite the lack of science to justify them .
Pack and Ariel, in the fifties, showed that lumpectomy as the primary treatment for breast cancer was just as effective as the disfiguring radical mastectomy, then universally prescribed, and obviously far less invasive. They were called quacks or even murderers by the surgical establishment. Of course they were right, but it took decades before their practice became standard.
So why is axillary node dissection a bad idea even without the current study? It’s because the axilla is not the only site of lymph drainage from the breast. It has been known for centuries that there are extra-axillary sites of lymph drainage from that organ. Thus the axilla is not the only site of lymph nodes that might contain malignant cells. Looking for evidence of lymphatic spread of breast cancer only in the axilla is akin to looking for your lost wallet only under a street light because it’s brighter there.
The initial hypothesis should have been that an axillary node dissection would convey no benefit as it obviously would not remove metastases present in extra-axillary sites. If a beast cancer has spread to lymph nodes it is highly likely that it has spread to all sites that drain the breast. Instead of adopting the practice of routine axillary dissection surgeons should first have done a study to show that it was beneficial. Of course they did the opposite. Devotion to scientific method is not strong in oncology. To make thing even worse axillary dissections have adverse consequences. They may cause infections and chronic lymphedema. The latter is a swelling of the arm resulting from surgically impaired lymph drainage that may range from mild to disabling. We had a dialysis patient who lost her forearm because of lymphedema secondary to an axillary dissection as treatment for her breast cancer.
“This is such a radical change in thought that it’s been hard for many people to get their heads around it,” said Dr. Monica Morrow, chief of the breast service at Sloan-Kettering and an author of the above study. This says a lot about what’s inside these heads. A general rule of thumb for those afflicted with cancer is to choose the most conservative treatment plan offered by a reputable cancer center.