ASCO Endorses 'Less Is More' for LND in Breast Cancer

Pam Harrison

December 13, 2016

Experts have again come out in favor of the "less-is-more" approach to breast cancer surgery and have endorsed previous recommendations not to automatically harvest all lymph nodes if cancer is found in a sentinel node, new guidelines from the American Society of Clinical Oncology (ASCO) indicate.

"The standard of care used to be to take all lymph nodes, but the data have been quite compelling over the last few years, and now, it's generally accepted that a complete lymph node dissection isn't necessary for all patients," lead author Gary Lyman, MD, MPH, Fred Hutchinson Cancer Research Center, Seattle, Washington, said in a statement.

"So if a woman has only one or two sentinel lymph nodes that are cancerous, and if the tumor is not too big and not too aggressive, there's no value in doing a complete lymph node dissection," he added.

The recommendations were published online December 12 in the Journal of Clinical Oncology.

Dr Lyman and colleagues reviewed a total of eight publications in an effort to validate guidelines issued by ASCO in 2014.

In their 2014 recommendations, ASCO authors stated that axillary lymph node dissection (ALND) can be avoided in patients with one or two positive sentinel nodes who undergo breast-conserving surgery, provided conventionally fractionated whole-breast radiation is planned.

The updated guidelines continue to recommend that surgeons not perform a full ALND when two or fewer sentinel nodes are involved, provided the tumor is not greater than 5 cm in size and patients have no nodal metastases.

On the other hand, ALND may be offered to women with early-stage breast cancer if there is evidence of nodal metastases in sentinel node biopsy specimens and if the patient is to undergo mastectomy.

Sentinel node biopsy may also be offered to women with operable breast cancer in a number of circumstances, Dr Lyman and colleagues comment.

These circumstances include the presence of multicentric tumors as well as ductal carcinoma in situ (DCIS) treated with mastectomy.

Women who have had prior breast or axillary surgery as well as those who have received preoperative or neoadjuvant systemic therapy are also candidates for sentinel node biopsy, Dr Lyman notes.

However, as Dr Lyman emphasized in an email to Medscape Medical News, when there is clinical evidence of axillary nodal involvement at baseline, reliance on sentinel node biopsy performed after neoadjuvant therapy appears to be associated with a lower sentinel node identification rate and a higher false negative rate than when performed preoperatively and is, therefore, not routinely recommended.

Sentinel node biopsy should also not be performed in women with either inflammatory breast cancer or those with DCIS when breast-conserving surgery is planned.

Pregnant women with early-stage breast cancer are also not candidates for sentinel node biopsy.

Dr Lyman observed that sparing women a full ALNB has many advantages.

"The most common complications of ALND are lymphedema due to disruption of the lymph vessels," he observed.

In addition, patients who undergo ALND are more prone to infection and risk a reduction in range of motion.

"Full removal is always an option, and some women want to have all of the lymph nodes taken out," Dr Lyman said.

"But given the downside of the full axillary dissection in terms of quality of life and possible complications, many women who have a lower risk say, 'I want to avoid these problems,' " he added.

Sentinel node biopsy can generally be performed as an outpatient procedure, whereas ALND often requires a hospital stay of up to 3 days, another real advantage in favor of sentinel node biopsy, Dr Lyman indicated.

Considerable Uptake

Dr Lyman observed that there has been "considerable uptake" in the use of sentinel node biopsy, both in the United States and elsewhere.

"This uptake has been most rapid and complete in larger community and academic hospitals and among surgeons who specialize in breast cancer," he acknowledged.

In contrast, the new recommendations is less likely to be followed in treating the elderly, members of minority groups, as well as those without insurance or with limited insurance.

This does not make much sense, Dr Lyman observed, given that both the cost and the risks associated with performing sentinel node biopsy in patients with early-stage breast cancer are lower than those of ALND.

"Referral to major centers or surgeons specializing in breast cancer surgery, along with continued education of general surgeons in more rural settings, appears warranted," Dr Lyman suggested.

"And efforts to reduce disparities based on age, race, and socioeconomic status are also needed," he added.

Dr Lyman has served in a consulting or advisory role with Halozyme and GI Therapeutics and has received research funding from Amgen.

J Clin Oncol. Published online December 12, 2016. Full text

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