The Nebraska Medical Center Cancer Center Blog

Never Leave a Little Cancer Behind? - Maybe

This past week a remarkable study suggested that in a very select group of women who have cancer in the sentinel node (the first lymph node to receive cancer cells from breast cancer) the removal of all their remaining lymph nodes may not be beneficial and may even hurt some. Removing the lymph nodes did not lead to better survival or decreased risk of cancer coming back.

As a surgical oncologist, there is no question in my mind that it will be a hard sell to convince my patients why a 27.3 percent chance that the lymph nodes with cancer left in their armpit will NOT affect their outcome. However, I do believe the findings are very reliable and need to be reviewed with patients in advance of their surgical treatment. Surgical oncologists will have to be more illustrative in their explanations regarding the findings in this study because patients in the U.S. seem swayed to be overly aggressive in regards to their cancer treatment and that is sometimes based on fear not facts.

Historically, breast cancer experts have removed the lymph nodes only to find out who would benefit from additional treatments such as chemotherapy after surgery. These experts have never been able to prove that removing the lymph nodes improved a patient’s chance of survival. Nearly 15 years ago, specially trained surgical oncologists invented the sentinel node biopsy technique. This reliable procedure allowed breast cancer specialists to find out which patients have cancer in their lymph nodes. Only 30 percent of all breast cancer patients have any cancer in their lymph nodes. As long as a patient has no cancer in their sentinel node, there is no need to remove the remaining lymph nodes. Removal of these lymph nodes causes unnecessary pain and other complications such as lymphedema which is a swelling of the arm.

The study examined women with smaller breast cancers (average size 2 cm) where cancer had spread to the sentinel node. All of these women completed radiation and chemotherapy as part of their treatment. The sentinel nodes were removed, but their other lymph nodes remained. These women did not have a worse survival or a higher cancer reoccurrence rate than women who had all of their lymph nodes removed. As a further benefit, these women were spared the 30 percent chances of lymphedema.

Among the women who only had the cancerous sentinel node removed, 27.3 percent of them had their other lymph nodes with microscopic cancer left in place. With the use of chemotherapy and radiation therapy there were no recurrences in the armpit or elsewhere after six years of following up with them. In most cases, if cancer is going to come back, it will show up within two years.

The study shows that in a selected number of women treated with chemotherapy and whole breast radiation after lumpectomy for small breast cancers with a positive sentinel lymph node additional surgery resulting in increasing complications such as lymphedema may be avoided after a thorough evaluation by the cancer surgeon and the breast cancer multidisciplinary treatment team.

New York Times article Study of Breast Biopsies Finds Surgery Used Too Extensively

Edibaldo Silva-Lopez, MD, PhD, FACS
Surgical Oncologist
The Nebraska Medical Center

Associate Professor, Surgical Oncology, University of Nebraska Medical Center

Call 800-922-0000 to make an appointment with Dr. Edibaldo Silva-Lopez. For clinic location and hours use the Find a Physician link.

Not Your Grandfather’s Colonoscopy

Colon cancer is curable when detected at an early stage. The challenge of detecting colon cancer at an early stage is the screening process. While discussing bowel movements and following through with an invasive procedure may be uncomfortable, finding colon cancers at an early stage often reduces the length, severity and cost of cancer treatment.

Patients may be too embarrassed to discuss a change in bowel habits, constipation or diarrhea with their physician. It may take them some time to realize there is blood in their stool, if the initial amount is small. Blood in the stool can be red streak, if the lesion is closer to the rectum and maybe black, if the lesion is away from the rectum. There are some cases where a patient may not recognize the symptom or write off some of the symptoms as having hemorrhoids and purchase over-the-counter products to treat.

When they do decide to discuss these symptoms with their physician and it is recommended for them to have a colonoscopy, some patients do not schedule the test. Often times they’ve heard the test can result in tearing of the colon and bleeding. But it’s not your grandfather’s colonoscopy anymore. The risks of tearing and bleeding are significantly lower over the years as endoscopists have gained more experience, developed better techniques and implemented best practice standards.

Even the preparation for the test has become more bearable. In the past, patients would have to drink a full gallon of a salty liquid, take laxatives and antibiotics. Today, the preparation is still not exactly pleasant, but there are new products available, some even flavored. More importantly, the amount of liquid laxative a patient must take in preparation has been reduced. In some cases a patient may only need one or two bottles the size of a soda.

When selecting an endoscopist, ask questions regarding the duration of the procedure and the number of samples collected.

There are three groups of patients who should consider getting a colonoscopy. The first group is made up of patients who have symptoms such as blood in their stool, a change in bowl habits or unexplained constipation or diarrhea. The other group of patients who should schedule regular colonoscopies is individuals with strong family history of colon cancer. And finally, the third group would be anyone over the age of 50.

After deciding to schedule a colonoscopy, there are questions you should ask before selecting a specialist to perform the test. There are two questions I advise patients to ask.

“What is the average length of time the tests you perform last?”

The reason this question is so important is because the colon is very long. You really want a physician who takes the time to inspect the colon thoroughly.

“What is your average number polypectomy (samples) per patients?”

This question is important because you want a physician who is willing to take several samples from various different locations.

For individuals over the age of 50 with no symptoms and no family history of colon cancer, fecal occult blood test (FOBT) screening kits are also available. This is a non-evasive test which can be done at home by collecting three samples of fecal matter on three different days and can detect blood in the stool and some cancers. The test does not typically pick up on any precancerous cells which may be present. These tests are better than no test at all for this population.

It is most important to remember that colon cancer is curable if discovered at an early stage. In an effort to accomplish this I encourage patients to be open about discussing changes in their bowel movements with their physician and following though to make a colonoscopy appointment when one is recommended. When selecting an endoscopist, ask questions regarding the duration of the procedure and the number of samples collected. Following these steps could increase the chance of living longer and cancer-free.

Quan Ly, MD
Surgical Oncologist
The Nebraska Medical Center

Assistant Professor, Surgical Oncology, University of Nebraska Medical Center

Call 800-922-0000 to make an appointment with Dr. Quan Ly. For clinic location and hours use the Find a Physician link.

QUICK TIP

Larra Petersen, PhD, Licensed Psychologist at The Nebraska Medical Center recently presented at the Brain Tumor Education and Support Group. "Despair, disbelief and disorientation are normal responses after the initial cancer diagnosis," she said. "Patients and caregivers might benefit from managing reactions to the diagnosis by challenging unrealistic and negative thoughts as well as adopting self-care strategies like exercising and surrounding yourself with several supportive people."

Larra R. Petersen, PhD
Clinical Psychologist
The Nebraska Medical Center

Call 800-922-0000 to make an appointment with Larra Petersen.

QUICK TIP

Deborah Hoffnung, PhD, ABPP, Clinical Neuropsychologist at The Nebraska Medical Center recently presented at the Brain Tumor Education and Support Group. She offered suggestions to those for coping with changes in personality resulting from a brain tumor. "It is important to recognize any personality change may be a symptom of the disease or treatment," she said. "Report changes to your doctor and be patient with yourself."

Deborah S. Hoffnung, PhD, ABPP
Clinical Neuropsychologist
The Nebraska Medical Center

Call 800-922-0000 to make an appointment with Deborah Hoffnung.

Cancer Survivorship Group - March 1

The Nebraska Medical Center
University Tower, Third Floor
Private Dining Room C

Meal at 5 p.m.
Group discussion from 5:30 to 6:30 p.m.

Presentation topic: Adjusting to a New “Normal” after Cancer by Alan L Hensley, PhD, BCETS, FAAETS, PLMHP, Board Certified Expert in Traumatic Stress and Fellow, American Academy of Experts in Traumatic Stress (AAETS)

Please call the Social Work department at 402-559-4420 if you plan to attend.