"A new study finds that many women with early breast cancer do not need a painful procedure that has long been routine removal of cancerous lymph nodes from the armpit. The discovery turns standard medical practice on its head. Surgeons have been removing lymph nodes from under the arms of breast cancer patients for  years believing it would prolong womens lives by keeping the cancer from spreading or coming back. Now researchers report that for women who meet certain criteria  about  percent of patients or  women a year in the United States  taking out cancerous nodes has no advantage. It does not change the treatment plan improve survival or make the cancer less likely to recur. And it can cause complications like infection and lymphedema a chronic swelling in the arm that ranges from mild to disabling. Removing the cancerous lymph nodes proved unnecessary because the women in the study had chemotherapy and radiation which probably wiped out any disease in the nodes the researchers said. Those treatments are now standard for women with breast cancer in the lymph nodes based on the realization that once the disease reaches the nodes it has the potential to spread to vital organs and cannot be eliminated by surgery alone. Experts say that the new findings combined with similar ones from earlier studies should change medical practice for many patients. Some centers have already acted on the new information. Memorial SloanKettering Cancer Center in Manhattan changed its practice in September because doctors knew the study results before they were published. But more widespread change may take time experts say because the belief in removing nodes is so deeply ingrained.  This is such a radical change in thought that its been hard for many people to get their heads around it said Dr. Monica Morrow chief of the breast service at SloanKettering and an author of the study httpjama.amaassn.orgcontent.full which is being published Wednesday in The Journal of the American Medical Association. The National Cancer Institute paid for the study. Doctors and patients alike find it easy to accept more cancer treatment on the basis of a study Dr. Morrow said but get scared when the data favor less treatment. The new findings are part of a trend to move away from radical surgery for breast cancer. Rates of mastectomy removal of the whole breast began declining in the s after studies found that for many patients survival rates after lumpectomy and radiation were just as good as those after mastectomy. The trend reflects an evolving understanding of breast cancer. In decades past there was a belief that surgery could get it all  eradicate the cancer before it could spread to organs and bones. But research has found that breast cancer can begin to spread early even when tumors are small leaving microscopic traces of the disease after surgery. The modern approach is to cut out obvious tumors  because lumps big enough to detect may be too dense for drugs and radiation to destroy  and to use radiation and chemotherapy to wipe out microscopic disease in other places. But doctors have continued to think that even microscopic disease in the lymph nodes should be cut out to improve the odds of survival. And until recently they counted cancerous lymph nodes to gauge the severity of the disease and choose chemotherapy. But now the number is not so often used to determine drug treatment doctors say. What matters more is whether the disease has reached any nodes at all. If any are positive the disease could become deadly. Chemotherapy is recommended and the drugs are the same no matter how many nodes are involved. The new results do not apply to all patients only to women whose disease and treatment meet the criteria in the study. The tumors were early at clinical stage T or T http meaning less than two inches across. Biopsies of one or two armpit nodes had found cancer but the nodes were not enlarged enough to be felt during an exam and the cancer had not spread anywhere else. The women had lumpectomies and most also had radiation to the entire breast and chemotherapy or hormoneblocking drugs or both. The study at  medical centers included  patients. Their median age was in the mids and they were followed for a median of . years. After the initial node biopsy the women were assigned at random to have  or more additional nodes removed or to leave the nodes alone. In  percent of the women who had additional nodes removed those nodes were cancerous. But over time the two groups had no difference in survival more than  percent survived at least five years. Recurrence rates in the armpit were also similar less than  percent. If breast cancer is going to recur under the arm it tends to do so early so the followup period was long enough the researchers said. One potential weakness in the study is that there was not complete followup information on  women about equal numbers from each group. The researchers said that did not affect the results. A statistician who was not part of the study said the missing information should have been discussed further but probably did not have an important impact. It is not known whether the findings also apply to women who do not have radiation and chemotherapy or to those who have only part of the breast irradiated. Nor is it known whether the findings could be applied to other types of cancer. The results mean that women like those in the study will still have to have at least one lymph node removed to look for cancer and decide whether they will need more treatment. But taking out just one or a few nodes should be enough. Dr. Armando E. Giuliano the lead author of the study and the chief of surgical oncology at the John Wayne Cancer Institute at St. Johns Health Center in Santa Monica Calif. said It shouldnt come as a big surprise but it will. Its hard for us as surgeons and medical oncologists and radiation oncologists to accept that you dont have to remove the nodes in the armpit. Dr. Grant W. Carlson a professor of surgery at the Winship Cancer Institute at Emory University and the author of an editorial accompanying the study httpjama.amaassn.orgcontent.extract said that by routinely taking out many nodes I have a feeling weve been doing a lot of harm. Indeed women in the study who had the nodes taken out were far more likely  percent versus  percent to have complications like infections abnormal sensations and fluid collecting in the armpit. They were also more likely to have lymphedema. But Dr. Carlson said that some of his colleagues even after hearing the new study results still thought the nodes should be removed. The dogma is strong he said. Its a little frustrating. Eventually he said genetic testing of breast tumors might be enough to determine the need for treatment and eliminate the need for many node biopsies. Two other breast surgeons not involved with the study said they would take it seriously. Dr. Elisa R. Port the chief of breast surgery at Mount Sinai Medical Center in Manhattan said Its a big deal in the world of breast cancer. Its definitely practicechanging. Dr. Alison Estabrook the chief of the comprehensive breast center at St. LukesRoosevelt hospital in New York said surgeons had long been awaiting the results. In the past surgeons thought our role was to get out all the cancer Dr. Estabrook said. Now hes saying we dont really have to do that. But both Dr. Estabrook and Dr. Port said they would still have to make judgment calls during surgery and remove lymph nodes that looked or felt suspicious. The new research grew out of efforts in the s to minimize lymph node surgery in the armpit called axillary dissection. Surgeons developed a technique called sentinel node biopsy in which they injected a dye into the breast and then removed just one or a few nodes that the dye reached first on the theory that if the tumor was spreading cancer cells would show up in those nodes. If there was no cancer no more nodes were taken. But if there were cancer cells the surgeon would cut out more nodes. Although the technique spared many women many others with positive nodes still had extensive cutting in the armpit and suffered from side effects. Women really dread the axillary dissection Dr. Giuliano said. They fear lymphedema. Theres numbness shoulder pain and some have limitation of motion. There are a fair number of serious complications. Women know it. After armpit surgery  percent to  percent of women develop lymphedema Dr. Port said and radiation may increase the rate to  percent to  percent. Physical therapy can help but there is no cure. The complications  and the fact that there was no proof that removing the nodes prolonged survival  inspired Dr. Giuliano to compare women with and without axillary dissection. Some doctors objected. They were so sure cancerous nodes had to come out that they said the study was unethical and would endanger women. Some prominent institutions wouldnt even take part in it Dr. Giuliano said though he declined to name them. Theyre very supportive now. We dont want to hurt their feelings. Theyve seen the light."