Women who are diagnosed with ductal carcinoma in situ (DCIS) frequently have lymph nodes removed during breast cancer surgery, even though medical guidelines recommend against it.
Studying the health records of 35,591 DCIS patients who were treated with either lumpectomy or mastectomy between 2006 and December 2012, researchers discovered that 29% of the women had lymph nodes removed during surgery: 84 had sentinel node biopsy (SLNB), while 16% had axillary lymph node dissection (ALND). SLNB removes one or two underarm lymph nodes; ALND removes several or all underarm lymph nodes.
Sampling lymph nodes is standard-of-care to stage the progress of invasive breast cancers: invasive ductal carcinoma, invasive lobular carcinoma and inflammatory breast cancer. Lymph nodes are removed and examined microscopically to help to determine whether the cancer has progressed beyond the breast, and the best treatment protocol.
Nationally recognized guidelines of both the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend against lymph node dissection in women who have DCIS that is treated with lumpectomy (the guidelines are less clear for DCIS-related mastectomy). No benefit has been associated with lymph node removal related to non-invasive DCIS, which typically remains within the breast. Guidelines recommend SLNB only when the suspicion of invasive breast cancer is high or when invasive breast cancer is discovered during surgery—as it is in about a fourth of women with DCIS who were originally diagnosed by a core biopsy.
In this study, researchers concluded that:
- 29% of the women studied had lymph nodes removed: 84.2% by sentinel lymph node biopsy (SLNB) and 15.8% by full axillary lymph node dissection (ALND).
- Among women who had mastectomy, 48% had SLNB and 15.2% had ALND.
- Among women who had lumpectomy, 16.7% had SLNB and 1% had ALND.
The study database reflected practices at more than 600 hospitals across the country, indicating that the trend is widespread. Most physicians included in the study were general surgeons; fewer than 5% were surgical oncologists. Surgeons who performed lumpectomy less often were more likely to perform some type of lymph node removal compared to high-volume surgeons—95% of studied mastectomies were performed by surgeons who operated for DCIS only once or twice a year.
Why the concern?
What is most disturbing about this study’s findings is how often lymph nodes were removed from DCIS patients, despite nationally recognized guidelines to the contrary. Aside from an additional 2-3” incision, numbness in the armpit, increased risk for infection, and added time under general anesthesia, the issue is significant for another reason. Removing lymph nodes frequently compromises the lymph system, which carries excess fluids and bodily debris away from the tissues. Removing lymph nodes can impair this functionality, leading to lymphedema, mild to pronounced swelling that results when fluids don’t drain adequately and back up in the tissues.
The risk for lymphedema rises with the number of lymph nodes removed; sentinel node biopsy carries less risk of disrupting normal lymph function than a full axillary dissection. Once lymphedema develops, it becomes a lifelong condition that must be carefully managed to keep symptoms from becoming severe.
If you’ve been diagnosed with DCIS, be sure to discuss the extent of your surgery with your physician.
Reference: Coromilas E, Wright JD, Huang Y, et al. "The influence of hospital and surgeon factors on the prevalence of axillary lymph node evaluation in ductal carcinoma in situ." Journal of the American Medical Association Oncology (2015); DOI: 10.1001/jamaoncol.2015.0389.