Lymph node dissection is not only expensive, it disables thousands of women unnecessarily. For example, a woman named Dana had a mastectomy accompanied by removal of the Iymph glands under her arm 8 years ago. In some women, the fluid that would normally drain through the Iymph channels backs up, causing swelling (Iymphedema). Aside from the limited use of her shoulder and limb, Dana suffers from bouts of cellulitis, infections that sometimes arise from mosquito bites or scratches, requiring her to be on long-term antibiotic management to prevent blood poisoning (septicemia). About 20% of the women who have their nodes removed develop measurable Iymphedema (note 14).
Some oncologists recommend a bone marrow transplant if more than 10 nodes are positive. But the value of adjuvant bone marrow transplantation has not been established.
Lymph nodes were once thought to be the instigators of disease, the source of metastatic dissemination. According to Virchow, malignancy, like the tubercle bacillus, traveled through the Iymph channels and proceeded in an orderly, mechanical fashion from the local site, progressing to the glands under the arms, and from there migrating to distant sites. We now know, contrary to Virchow's theories proposed a dozen decades ago, that the proliferation of malignancy is neither orderly nor mechanical.
Radiation is a known carcinogen that can produce irritable, red, inflamed tissue in the short term; and stiff, thickened, desensitized tissue over time. Radiation following lumpectomy has no proven impact on survival, though it does affect local recurrence. Women who recur have an increased mortality, not because of the local tumor, but because recurrence is the manifestation of biologically more aggressive disease. Recurrence, however, is only symptomatic of increased risk of metastases, not the cause of the disease's spread. Removing the possibility of recurrence no more enhances a woman's health than removing the speedometer of a car alters its speed.
In rural areas like the outlying plains of North Dakota, where women must travel 6 or 8 hours to receive radiation therapy, mastectomy has been recommended over lumpectomy to prevent local recurrence. But women who do not receive radiation following lumpectomy have the same chance of survival as those who do.26, 40,41 The only difference is in the likelihood of local recurrence: 40% of women who do not receive radiation therapy will have a local recurrence within 10 years, whereas 15% who have had radiation following their lumpectomy will have a local recurrence within 10 years. It seems difficult for us to comprehend that how long a woman lives is not dependent on whether the local disease returns. It is not local disease that is life threatening, but the rapidity with which metastatic disease proceeds--something that there is no way to predict as of yet.
Women who recur within 2 years have a 20% chance of living 10 years, whereas women who recur after 5 years have the same chance of survival as those who do not. Recurrence within 2 years may serve as a more valuable marker of disease progression than any other.42 It was shocking when Fisher's study40 demonstrated that local recurrence did not impact survival. Yet doctors seldom make this clear to patients.38(p74) Because the value of radiation is questionable, its role following lumpectomy is currently under scrutiny.
Intensive Follow-Up: Chest X-Rays and Bone Scans
The effort to secure medical certainty is costly, elusive, and usually futile. Because elite medical schools are swollen with prestige, power, and funds, and because their libraries bulge with data, there is a public illusion that medicine is equipped to remedy our complaints. Because people think their doctors are so smart, they find it impossible to believe that they don't know how to help. People want prognostic and diagnostic as well as therapeutic answers.