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Reducing Treatment Seems Safe for Older Women With Early-Stage, Hormone-Receptor-Positive Breast Cancer

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Skipping sentinel lymph node biopsy and/or radiation therapy didn’t affect rates of recurrence (the cancer coming back) or survival for women age 70 and older diagnosed with early-stage, hormone-receptor-positive, HER2-negative, clinically node-negative breast cancer, according to a study.

The research was published on April 15, 2021, by the journal JAMA Network Open. Read the abstract of “Outcomes After Sentinel Lymph Node Biopsy and Radiotherapy in Older Women With Early-Stage, Estrogen Receptor-Positive Breast Cancer.”

Clinically node-negative means that your doctor thinks there is no cancer in the lymph nodes, based on a physical exam.

What is sentinel lymph node biopsy?
About radiation therapy
Treating breast cancer in older people
About the study
What this means for you

What is sentinel lymph node biopsy?

In sentinel lymph node biopsy, also called sentinel lymph node dissection, the surgeon looks for the very first lymph node that filters fluid draining away from the area of the breast that contained the breast cancer. If cancer cells are breaking away from the tumor and traveling away from your breast via the lymph system, the sentinel lymph node is more likely than other lymph nodes to contain cancer.

The idea behind sentinel node dissection is to get important information to guide treatment with the least possible surgery and trauma. Instead of removing 10 or more lymph nodes and analyzing all of them to look for cancer, the surgeon can remove only the one node that is most likely to have it. If this node is clean, chances are the other nodes have not been affected. In reality, the surgeon usually removes a cluster of two or three nodes — the sentinel node and those closest to it.

Strategic removal of just one or a few key underarm nodes can accurately assess overall lymph node status in women who have relatively small breast cancers (smaller than 5 cm) and who have lymph nodes that don't feel abnormal before surgery.

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About radiation therapy

Radiation therapy uses special high-energy X-rays or particles to damage a cancer cell’s DNA. When a cancer cell’s DNA is damaged, it can’t divide successfully and it dies.

Radiation therapy damages both healthy cells and cancer cells in the treatment area. Still, radiation affects cancer cells more than normal cells. Cancer cells grow and divide faster than healthy cells and also are less organized. Because of this, it's harder for cancer cells to repair the damage done by radiation. So cancer cells are more easily destroyed by radiation, while healthy cells are better able to repair themselves and survive the treatment.

Radiation therapy is recommended for most people who have lumpectomy to remove breast cancer and may sometimes be recommended after mastectomy, based on the size of the cancer and your personal risk of recurrence.

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Treating breast cancer in older people

As with many other diseases, the risk of breast cancer goes up as you get older. About 25% of breast cancers are diagnosed in people older than 75. Still, there are few official guidelines for treating breast cancer in people of this age group because they are often excluded from clinical trials because of their age.

Doctors know that older people are more likely than younger people to have side effects from breast cancer treatment because older people are more likely to have other medical conditions, such as high blood pressure or heart problems. These side effects can have a big effect on older people’s quality of life and their ability to do daily tasks such as dressing, eating, and bathing.

When an older person is diagnosed with early-stage breast cancer, doctors have to weigh the benefits of treatment with the risks, which include side effects and overtreatment. Overtreatment means treatments are given that don’t lower the risk of recurrence or improve survival.

To avoid overtreatment, the Society of Surgical Oncology adopted the Choosing Wisely guideline, which was created by the American Board of Internal Medicine. The Choosing Wisely guideline recommends against routinely using sentinel lymph node biopsy in people older than 70 diagnosed with early-stage, hormone-receptor-positive, clinically node-negative breast cancer.

Also, the National Comprehensive Cancer Network guideline says that as long as people older than 70 diagnosed with early-stage, hormone-receptor-positive, HER2-negative, clinically node-negative breast cancer are treated with tamoxifen after surgery, it’s likely they can skip radiation therapy.

Still, research shows that doctors don’t often follow these guidelines and continue to treat older people diagnosed with early-stage, hormone-receptor-positive, HER2-negative breast cancer with both sentinel lymph node biopsy and radiation therapy after surgery.

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About the study

In this study, the researchers wanted to see if skipping sentinel lymph node biopsy and radiation after breast cancer surgery affected either recurrence rates or disease-free survival in people age 70 and older diagnosed with early-stage, hormone-receptor-positive, HER2-negative, clinically node-negative breast cancer.

Disease-free survival is how long a person lives without the cancer coming back.

The study included information from 3,361 women age 70 and older diagnosed with that particular type of breast cancer between 2010 and 2018. All the women were treated through the University of Pittsburgh Medical Center health system.

Overall:

  • 2,195 (65.3%) had sentinel lymph node biopsy
  • 1,828 (54.4%) had radiation therapy after breast cancer surgery

Rates of sentinel lymph node biopsy rose about 1% per year, a trend that continued even after the Choosing Wisely guideline was adopted in 2016.

Rates of radiation therapy decreased about 3% per year.

To maximize follow-up time, the researchers limited their analysis to 2,109 women who were diagnosed between 2010 and 2014. About half the women in this group were followed for less than 4 years and half were followed for a longer time.

Of this group:

  • 1,373 (65.1%) had sentinel lymph node biopsy
  • 1,219 (57.8%) had radiation therapy after breast cancer surgery

The rates of recurrence and disease-free survival were the same for women who had sentinel lymph node biopsy and/or radiation therapy compared to women who didn’t have these procedures.

"As a breast surgeon, I want to give my patients the best chance of survival with the best quality of life," senior author Priscilla McAuliffe, M.D., Ph.D., surgical oncologist at the University of Pittsburgh Medical Center Hillman Cancer Center, said in a statement. "However, we have found that overtreatment of early-stage breast cancer in older patients may actually cause harm while not improving recurrence or survival rates."

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What this means for you

If you’re age 70 or older and have been diagnosed with early-stage, hormone-receptor-positive, HER2-negative, clinically node-negative breast cancer and are deciding on your treatment plan, you may want to talk to your doctor about this study.

You may be able to skip lymph node surgery, as well as radiation therapy after lumpectomy.

As you are making your treatment plan, you and your doctor will consider a number of factors, including:

  • your age
  • the size of the cancer
  • the grade of the cancer
  • any other health conditions you have
  • your family history of cancer
  • your personal preferences

Together, you can make the best treatment decisions for your unique situation.

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Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, M.D., medical adviser


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