Individualising treatment of axillary nodes in breast cancer

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Published: 8 Dec 2017
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Prof Tari King - Brigham and Women’s Cancer Center, Boston, USA

Prof Tari King speaks with ecancer at SABCS 2017 to discuss the subject of her plenary presentation from the conference - Individualising treatment of auxiliary nodes.

She summarises the history of lymph node biopsy in breast cancer, noting the advent of sentinel node biopsy and trends towards minimising scale and necessity of surgical intervention.

For more on minimising impacts of breast cancer surgery, read the Umberto Veronesi ecancermedicalscience memorial journal, here.

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As we’ve learned more about the biology of breast cancer we know that it’s not just one disease, it’s really a family of diseases. That has helped us a lot in our understanding of which type of breast cancer needs which type of treatment. So we’ve really moved away from a one-size-fits-all approach to a more tailored approach for each individual patient. This first started with our medical oncology colleagues and their use of chemotherapy versus endocrine therapy based on molecular subtype, and now this is also extending into our local therapy options where we’re making decisions regarding management of the breast cancer in the breast, as well as regarding management of the lymph nodes based on the biology of the disease, what the woman’s systemic treatment options are and what we know about her risks of local recurrence. It’s really an exciting time for physicians and for patients, because we get to tailor our strategies in surgery. In particular, we’ve really adopted a less-is-more approach. We’ve identified several areas where we can do smaller surgeries or less surgery and women still have equally good oncologic outcomes as with the bigger procedures. Obviously the advantage of the smaller procedures is less morbidities, less side effects of the surgery. This is particularly true when it comes to management of the axillary lymph nodes.

Traditionally, or historically, the only way we could determine whether there was cancer in the lymph nodes or not was to remove them all, a procedure called axillary lymph node dissection. The problem with that procedure is that it puts women at increased risk for arm swelling or lymphedema. This is really one of the most feared complications among women with respect to their breast cancer treatment. In the mid-1990s we saw the introduction of a procedure called the sentinel lymph node biopsy, which was a procedure that helps us to identify the first set of lymph nodes that the breast strains to, the guards or the gatekeepers, if you will, for all the lymph nodes under the arm. We learned then that if we removed just the sentinel lymph nodes, test them to see if there’s cancer in them, that that would tell us the status of the rest of the axillary base. If there was no cancer in the sentinel lymph nodes we didn’t have to remove additional nodes. That was a huge paradigm shift for both doctors and women and allowed us to reduce the number of women getting axillary node dissection and therefore subsequently reduce the number of women that were at increased risk for arm swelling or lymphedema.
Up until recently we still thought that if there was cancer in the sentinel nodes that we needed to remove additional lymph nodes. In the last five years or so we’ve now learned that if women have a small amount of cancer, let’s say cancer in one or two sentinel lymph nodes, we no longer have to remove all the additional lymph nodes, so we avoid again the morbidity of the axillary node dissection even for women with positive nodes. We learned that this was safe from several prospective clinical trials that tested the axillary node dissection, the standard treatment, versus either axillary observation or axillary radiotherapy to control any potential remaining disease. The results of those studies, now with over five years of follow-up, have all demonstrated that the rates of axillary recurrence or regional recurrence are quite low, and they’re not any different whether we do axillary node dissection or whether we simply observe in selected patients or do radiation in selected patients. So again moving away from treatments that aren’t adding any benefit but are adding morbidity.
Finally more recently we are really expanding the opportunities for women with node-positive disease by using pre-operative chemotherapy in an attempt to eradicate or kill disease that’s in the lymph nodes and then taking those patients to surgery and again using the sentinel node procedure to see if we can prove that the chemotherapy has eradicated the cancer, thereby again allowing us to avoid the morbidity of axillary node dissection, even in women who we know had cancer in the lymph nodes before they started treatment. So really trying to use a combination of what we’ve learned about the biology of breast cancer, what we’ve learned about responses to systemic therapy, risks of recurrence over time, and really tailor and dial back how much local therapy we need to provide to minimise the morbidity but to still allow women to have excellent oncologic outcomes.

Treating a patient as an individual person.

Yes.

Seems like a good idea.

With an individual cancer, yes.