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ASCO: SLNB an option for more women with operable breast cancer

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March 24, 2014

ASCO today issued expanded recommendations for the appropriate use of sentinel lymph node biopsy as an alternative to axillary lymph node dissection among patients with early-stage breast cancer.

The guidelines — developed by members of an ASCO Expert Panel who reviewed relevant literature between 2004 and 2013 — recommend sentinel lymph node biopsy (SLNB) among women with operable breast cancer who have multicentric tumors or ductal carcinoma in situ when mastectomy is performed. Women who underwent prior breast and/or axillary surgery and neoadjuvant systemic therapy also are recommended to undergo SLNB.

“The updated guideline incorporates new evidence from more recent studies — nine randomized controlled trials and 13 cohort studies since 2005,” Armando Giuliano, MD, FACS, co-chair of the expert panel, said in a press release. “Based on these studies, we’re saying more patients can safely get sentinel node biopsy without axillary lymph node dissection. These guidelines help determine for whom sentinel node biopsy is appropriate.”

The guidelines recommend against SLNB among women with large or locally advanced invasive breast cancers, inflammatory breast cancers or ductal carcinoma in situ when breast-conserving therapy is planned. It also recommends against SLNB for women who are pregnant. 

Axillary lymph node dissection is not recommended for women without sentinel lymph node metastases, or for most women with one to two metastatic sentinel lymph nodes who are planning to receive breast-conserving surgery and whole-breast radiation therapy.

However, axillary lymph node dissection is appropriate for women with metastatic sentinel lymph nodes undergoing mastectomy, according to the guidelines.

Gary H. Lyman, MD, MPH 

Gary Lyman

The report is an update to the 2005 guidelines, which recommended SLNB as an alternative to axillary lymph node dissection only among women with tumor-free lymph nodes.

“We strongly encourage patients to talk with their surgeon and other members of their multidisciplinary team to understand their options and make sure everybody’s on the same page,” Gary Lyman, MD, MPH, co-chair of the expert panel, said in the press release. “The most critical determinant of breast cancer prognosis is still the presence and extent of lymph node involvement and, therefore, the lymph nodes need to be evaluated so we can understand the extent of this disease.”

Disclosure: The researchers report no relevant financial disclosures.

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Nancy E. Davidson, MD

Nancy E. Davidson, MD

So often, oncology research ends up being about how to do more. The breast surgery research and practice community has distinguished itself by a sustained, rigorous and successful research effort to figure out when it is appropriate to do less. Informed by an enhanced understanding of breast cancer biology and natural history as well as technical developments in ways to identify sentinel nodes, a number of randomized trials challenged the dogma that all women with early breast cancer must undergo axillary dissection. This ASCO guideline synthesizes our current understanding from these trials about how best to manage the axilla in patients with early-stage breast cancer. The results from these trials help to identify those patients who should not undergo axillary dissection after sentinel node biopsy (eg, those with negative nodes or involvement of one or two sentinel nodes who will receive whole breast radiotherapy), as well as those who should not undergo sentinel node biopsy (eg, those with T3 or T4 tumors or ductal carcinoma in situ when breast-conserving surgery is planned). Many gray areas remain where clinicians and patients will need to extrapolate from imperfect data, and the ASCO guidelines will help guide these discussions. In sum, these guidelines are another important step in the path to optimize and personalize cancer care, and they are a reminder that more is not always better.

Nancy E. Davidson, MD
HemOnc Today Editorial Board member

Disclosure: Davidson reports no relevant financial disclosures.