New Guideline Limits Need for Extensive Lymph Node Removal for Breast Cancer

Submitted by Stony Brook Surgery on Wed, 03/26/2014 - 15:47

<p><div class="subhead"><em>Recommendations Will Spare Many Women the Painful Arm Swelling from Lymphedema</em></div></p>

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<a href="/surgery/people/faculty/dr-brian-j-ohea">
<img src="/sdmpubfiles/O%27Hea%20at%20Podium.jpg" width="158" height="225" alt="Dr. Brian O&#39;Hea at Podium" title="Dr. Brian O&#39;Hea at Podium" /></a>
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Dr. Brian J. O'Hea</div></div>

<P>Sentinel node biopsy (SNB) is used to determine if cancer has spread beyond the place where it started and into the nearby lymph nodes. SNB has been an important advancement in improving the quality of life of breast cancer patients.</P>

<P>In SNB, only a few lymph nodes are removed and examined for signs of cancer. Usually, if there is no cancer in these sentinel nodes, it means the remaining lymph nodes do not have cancer. The procedure can cause side effects, but they are much less common than with axillary lymph node dissection (ALND).</P>

<P>ALND involves removing most lymph nodes under the arm on the same side as the breast tumor, and examining the nodes for signs of cancer spread. The ALND procedure, which sometimes is still necessary, can cause long-term side effects including pain and numbness in the arm and <a href="http://stonybrookphysicians.staywellsolutionsonline.com/Search/85,P0014…; target="_blank">lymphedema</a>, a condition that causes swelling because of a build-up of lymph fluid.</P>

<p>An early proponent of SNB, <a href="/surgery/people/faculty/dr-brian-j-ohea">Brian J. O'Hea, MD</a>, chief of <a href="/surgery/patient-care/clinical/breast-surgery">breast surgery</a> and director of Stony Brook's Carol M. Baldwin Breast Care Center, says: "Sentinel node biopsy is now standard treatment. It has been shown to be a safe and accurate alternative to full axillary surgery in patients with breast cancer."</p>

<P>SNB has been used effectively at Stony Brook Medicine since the 1990s, the decade that saw the advent and validation of the procedure in the management of breast cancer.</P>

<div class="callout"><P><B>Evidence from clinical trials now supports using sentinel node biopsy in a larger group of patients.</B></P></div>

<P>The <a href="http://www.asco.org&quot; target="_blank">American Society of Clinical Oncology</a> (ASCO) has issued new recommendations for the use of SNB in patients with early breast cancer. The guideline, "<strong>Sentinel Lymph Node Biopsy for Patients with Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update,</strong>" was just published in the <em>Journal of Clinical Oncology</em>.</P>

<P>Since the Society issued its initial guideline in 2005, evidence from clinical trials now supports using the less invasive diagnostic technique, SNB, in a larger group of patients. This updated guideline will enable more women with early-stage breast cancer to avoid the more invasive ALND, which has a greater risk of complications.</P>

<P>"The updated guideline incorporates new evidence from more recent studies — nine randomized controlled trials and 13 cohort studies since 2005," says Armando Giuliano, MD, co-chair of ASCO's Expert Panel that updated the guideline. "Based on these studies, we're saying more [but not all] patients can safely get sentinel node biopsy without axillary lymph node dissection. These guidelines help determine for whom sentinel node biopsy is appropriate." </P>

<P>Commenting on the new guideline, Dr. O'Hea explains: "Sentinel node biopsy, as an alternative to ALND, is the single greatest advance in the surgical treatment of breast cancer since lumpectomy was proposed as an alternative to mastectomy some 40 years ago. As a result, many women, even some with positive sentinel nodes, can be been spared ALND, without any survival detriment."</P>

<P>"Unfortunately, not all women are beneficiaries of this technology, as some women still require ALND. We can only hope that as our understanding of the biology of breast cancer matures, and our treatments continue to improve, most if not all women will be able to be treated without radical armpit surgery.</P>

<P>"ASCO should be commended for establishing this very important guideline. We can only hope that the new recommendations will penetrate deeply into our healthcare system, and that all breast cancer physicians embrace and implement changes that are in the best interest of patients."

<div class="callout"><B><P>Some women even with positive nodes can be treated without extensive lymph node removal (ALND).</P></B></div>

<P> The guideline updates three recommendations based on evidence from randomized controlled trials:</P>

<UL>
<li class="innertext"><span>Women without sentinel lymph node metastases should not undergo ALND.</span></li>
<li class="innertext"><span>Most women with 1 to 2 metastatic sentinel lymph nodes planning to have breast-conserving surgery with whole breast radiotherapy should not undergo ALND (in most cases).</span></li>
<li class="innertext"><span>Women with sentinel lymph node metastases who will undergo mastectomy may be offered ALND.</span></li>
</UL>

<P>The guideline updates two groups of recommendations based on cohort studies and/or informal consensus: </P>

<UL>
<li class="innertext"><span>Women with operable breast cancer and multicentric tumors, and/or <a href="http://stonybrookphysicians.staywellsolutionsonline.com/Search/36,CDR00…; target="_blank">ductal carcinoma in situ</a> who will undergo mastectomy, and/or had prior breast and/or axillary surgery, and/or had preoperative/neoadjuvant systemic therapy may be offered SNB.</span></li>
<li class="innertext"><span>Women who have large or locally advanced invasive breast cancers (tumor size T3/T4), and/or inflammatory breast cancer, and/or ductal carcinoma in situ, when breast-conserving surgery is planned, and/or are pregnant should not have SNB.</span></li>
</UL>

<P>The ASCO committee noted that in some cases, evidence was insufficient to update previous recommendations.</P>

<P>"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," says Gary Lyman, MD, MPH, co-chair of the Expert Panel. "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 the disease."</P>

<P>To update the guideline, ASCO convened experts in medical oncology, pathology, radiation oncology, surgical oncology, guideline implementation and advocacy. The committee conducted a systematic review of the literature published from February 2004 to January 2013 in <a href="http://www.nlm.nih.gov/bsd/pmresources.html&quot; target="_blank">Medline</a> and based its recommendations on review of the evidence. It also includes an appendix on pathology.</P>

<P><span class="pointer"><strong>See the <a href="http://jco.ascopubs.org/content/early/2014/03/18/JCO.2013.54.1177.full…; target="_blank">new practice guideline</a>, plus <a href="http://www.cancer.net/research-and-advocacy/asco-care-and-treatment-rec…; target="_blank">patient information</a>. Read about the sentinel node biopsy <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC139441/&quot; target="_blank">history and validation</a>. For a consultation/appointment with one of our breast surgeons, please call 631-638-1000.</strong></span></P>