Treatment Options for Lymph Node-Positive Breast Cancer

Doctor examining patient's lymph nodes
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If your breast cancer has spread to your lymph nodes your treatment choices will often be more aggressive. With early-stage breast cancers, we can't be certain which cancers might spread (metastasize). Since metastases are responsible for 90 percent of breast cancer deaths, knowing when to treat aggressively, and when adjuvant treatments like chemotherapy may be overkill, is important. When breast cancer spreads to lymph nodes it has essentially declared its "intent" to metastasize. These cancers, if left alone, would likely spread throughout the body and eventually cause death.

What are the treatments for breast cancer that has spread to lymph nodes, and what does this mean for your prognosis?

Why Lymph Nodes Are Important in Breast Cancer

Breast cancer starts out with just a few cells, which group together in your breast tissue. They may be camping out in the system where breast milk is produced: your milk ducts and lobes. As these cells grow and divide, they may also invade nearby tissue.

A growing tumor may shed a cell or a clump of cells. This independent cancer cell can use your blood or lymph system like a network of highways so it can travel throughout your body. Your lymph system works with your circulating blood to provide nutrients to all your cells, as well as remove cellular waste products. The lymph nodes are the "pit stops" on this highway system, where the lymphatic fluid is filtered, mixed with immune cells (lymphocytes), and passed back into your circulating lymph fluid.

So, if a loose cancer cell makes it to your lymph nodes, it's also possible that cancer could get sent along to other parts of your body. If you get an infection, your lymph nodes near the affected area may swell because they have collected germs. And if you develop breast cancer, the lymph nodes in your armpit (axillary lymph nodes) are the most common place that cancer cells would lodge, causing those nodes to swell.

Diagnosis Using Sentinel Lymph Node Biopsy

Breast tissue itself contains some lymph nodes, which process lymphatic fluid and pass it along. Breast tumors most commonly drain towards your axilla or underarm area. Checking the underarm lymph node location should be part of a clinical breast exam, as well as your breast self-exam. Swollen lymph nodes might be evidence that cancer has spread beyond your breast, but the only way to know for sure is to have them removed and tested.

There are two procedures for lymph node biopsy. In a sentinel lymph node biopsy, a dye and a radioactive marker are injected into your breast cancer. The first node or nodes that the dye travels to are called the sentinel lymph nodes—the first nodes to which cancer would be expected to travel.

An alternative to a sentinel lymph node biopsy is to do an axillary lymph node dissection. In this procedure, all of the lymph nodes which can be found in your armpit are removed. We have learned that finding cancer cells in your sentinel lymph nodes is an excellent predictor of whether or not cancer will be found in any of your remaining lymph nodes.

Axillary lymph nodes are most commonly the first place to which breast cancer spreads but there are some exceptions. Breast cancers towards the middle of your chest may instead drain to lymph nodes between your breasts. When lymph nodes are removed they are sent to the pathology department to be looked at visually and under the microscope.

Lymph Node Status

The pathology report about your lymph node "status" tells whether or not any sign of cancer is present in your lymph nodes which were removed. You may hear words such as macrometastases or micrometastases when your surgeon discusses your nodes. Macrometastases refer to the spread of cancer to lymph nodes which is visible to the naked eye. Micrometastases instead refer to evidence of cancer in the lymph nodes which can only be seen under the microscope.

If your lymph nodes are clear of cancer, your lymph node status is called negative and rated N0 according to the TNM staging of breast cancer. If you have a small tumor and clear nodes, it's less likely that you will need chemotherapy.

If you have cancer cells in your lymph nodes, your cancer would be considered lymph node-positive. Based on TNM staging, your tumor would be called either N1, N2, or N3 based on how many lymph nodes contain cancer cells and how far away from the tumor the positive nodes are found.

Other Important Results in Treatment and Prognosis

Lymph node status is one of the major factors in making decisions about breast cancer treatment, but there are other tests which play a role in both treatment and prognosis as well. These include:

  • Tumor size: Tumor size plays a role in breast cancer staging.
  • Hormone receptor status: Your cancer cells will be tested to determine your hormone receptor status, that is, whether or not your cancer cells have receptors for estrogen or progesterone on the surface, as that helps guide treatment choices.
  • HER2 status: Human growth factor epidermal receptor 2, if present on your cancer cells, also plays a role in diagnosis and treatment.
  • Tumor grade: Tumor grade is a measure of the aggressiveness of the cancer and this test may guide treatment options.
  • Presence of any metastases: If your cancer has spread to other regions of the body, for example, your bones or your lungs, this is important in selecting treatment options.

Treatments for People With Positive Nodes

If you have a sentinel node biopsy and it is negative, you will likely not need to have an axillary lymph node dissection. In contrast, if you have cancer cells present in your sentinel lymph node, axillary node dissection may be included along with your breast cancer surgery. If your lymph nodes are positive, you will need to discuss further treatment options with your oncologist after surgery.

Having involved lymph nodes suggests that cancer has demonstrated an ability to spread beyond your breast and you will be advised to have adjuvant systemic therapy such as chemotherapy to kill any additional cancer cells that persist in your body. Adjuvant treatment refers to treatment that is given not because any cancer is seen, but because it is suspected that there may be additional cancer cells present.

For those who have estrogen receptor-positive tumors, hormonal therapy is usually recommended for 5 to 10 years after treatment. This may be tamoxifen for those who are premenopausal and an aromatase inhibitor for those who are postmenopausal. For postmenopausal women who will be using an aromatase inhibitor, the bisphosphate medication Zometa is recommended as well as it appears to reduce the risk of developing bone metastases. The bones are the most common site of metastases with breast cancer.

Radiation therapy may or may not be recommended depending on the number of lymph nodes which are positive, and other findings of your tumor.


Prognosis, also called outlook, is one way a doctor talks about how the odds for survival stack up for you after you've completed treatment. Remember, having just one cancer cell in your body is one too many. Treatment is designed to kill off as many, if not all, of your cancer cells as possible.

If you had clear lymph nodes and a small, low-grade tumor, your prognosis after treatment is pretty good. On the other end of the spectrum, if you had several lymph nodes involved or a larger tumor, your treatment will likely be more aggressive, and your outlook will be harder to determine until after you've finished all treatments. An article published in New England Journal of Medicine shows a significant risk of recurrence in patients with four or more positive lymph nodes. Also. tumor size is an independent prognostic factor.

No matter where your diagnosis fits on that scale, please know that survival rates are improving, treatments are becoming more efficient and effective, and even metastatic breast cancer can sometimes be managed for a long period of time.

Lymph Node Rating

Lymph Node Rating Meaning of Rating
N0 Negative or clear: Contains no cancer and no micrometastasis
N1 Positive: Cancer is found in 1-3 lymph nodes under the arm or lymph nodes within the breast
N2 Positive: Cancer is found in 4-9 lymph nodes under the arm or lymph nodes within the breast
N3 Positive: Cancer is found in 10 or more lymph nodes under the arm or has spread under or over the collarbone. It may have been found in the underarm nodes as well as lymph nodes within the breast

A Word From Verywell

If you have positive lymph nodes with early-stage breast cancer, treatments will likely be more aggressive and include chemotherapy, hormonal therapy, HER2 targeted therapy for those who are HER2 positive, and possibly radiation. That said, many people with lymph node-positive cancer remain cancer-free after treatment, and a positive lymph node status does not automatically mean your cancer will come back. 

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