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Poor women get more unneeded breast cancer surgery

By Frederik Joelving

NEW YORK (Reuters Health) - Old, poor and Hispanic women are all more likely to have lymph nodes under the armpit removed unnecessarily during breast cancer surgery, a new study finds.

That's despite 2005 guidelines recommending a gentler surgery that spares most of the lymph nodes, avoiding side effects like pain, swelling and numbness down the line.

Based on a California cancer registry, researchers found that more than a third of some 18,000 women who had undergone mastectomy for early-stage breast cancer had had their lymph nodes removed as well -- a procedure known as axillary lymph node dissection, or ALND.

Yet all of these women had node-negative tumors, meaning the cancer hadn't spread beyond the breast.

Since the mid 2000s, the American Society of Clinical Oncology has urged doctors to consider removing only the lymph nodes closest to the tumor -- called sentinel lymph nodes -- to see if the disease has spread beyond the breast.

Even if it has, a study released earlier this year in the Journal of the American Medical Association suggested removing the lymph nodes doesn't help women live longer, as long as they are getting radiation and chemotherapy.

Dr. Sharon Lum, a breast surgeon who worked on the new study, said certain women appeared to be more at risk of having their lymph nodes removed for no apparent reason.

"The women that were getting this unnecessary surgery were more likely to be of lower socioeconomic status, were older, or were Hispanic," Lum, of Loma Linda University in California, told Reuters Health.

It's hard to tease out why that is based on the registry data. The gentler surgery isn't more expensive, Lum said, but it does require more coordination between different departments, adding an extra step that some surgeons might prefer to avoid.

"There are surgeons that choose not to do it, and there are patients that don't know it's better," she explained. "The take-home message for patients and surgeons is, you have to be educated about the downstream consequences of the surgery you choose to do."

In an editorial published along with the study in the Archives of Surgery, Dr. Jan H. Wong, of East Carolina University in Greensville, North Carolina, says the study raises troubling questions.

"Do these data lend further evidence to the difficulty of translating evidence-based recommendations of care into clinical practice? If so, what are the reasons for this and how might this be corrected? Might these data suggest the selective management of women with early breast cancer based on the level of insurance coverage?" Wong writes.

He adds that the study is "a wake-up call that health care systems need to more rigorously examine the process of care and to intervene with corrective action where appropriate."

SOURCE: http://bit.ly/oJk1hK Archives of Surgery, September 19, 2011.

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