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ASCO guidelines for sentinel node biopsies remain unchanged
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No new evidence warrants revisions to ASCO’s 2014 recommendations on the use of sentinel node biopsy for women with early-stage breast cancer, according to an expert panel review of randomized controlled trials, meta-analyses and clinical practice guidelines.
These recommendations include that axillary lymph node dissection (ALND) should not be performed in women without nodal metastases or in women who have one or two nodal metastases and will undergo breast-conserving surgery with radiation.
“As clinical trials mature and ultimately complete final analysis, it was important to systematically review and consider any new emerging data,” Gary H. Lyman, MD, MPH, member of Fred Hutchinson Cancer Research Center, professor in the division of medical oncology at University of Washington, and medical oncologist at Seattle Cancer Care Alliance, told HemOnc Today. “ASCO annually updates the search strategy. When new studies are found, an update is undertaken.
“There are no major changes in recommendations in this update compared to the major changes in 2014,” Lyman added. “Nevertheless, it is important to restate those recommendations and report that additional evidence generated has not changed those recommendations. Importantly, the panel recommends no routine full axillary dissection when two or fewer sentinel nodes are involved in patients with no clinical evidence of axillary lymph node disease, and sentinel node biopsy [SNB] can be utilized following neoadjuvant chemotherapy prior to lumpectomy and radiation therapy, although the false-negative rate appears to be greater than when performed before chemotherapy.”
A search yielded 184 abstracts from PubMed and the Cochrane Library published from 2012 through July 2016, eight of which the expert panel selected for review.
The recommendations include that clinicians should not recommend ALND for women with early-stage breast cancer who do not have nodal metastases.
“Common complications with complete ALND are lymphedema and an increased risk for infection,” Lyman said. “The risk for these complications is significantly less when SNB alone is appropriate. SNB is generally an outpatient procedure while often hospitalization may be need for complete dissection. Therefore, patient quality of life and costs are less with SNB alone when appropriate.”
Other recommendations include that:
- Clinicians should not recommend ALND for women with early-stage breast cancer who have one or two sentinel lymph node metastases and will receive breast-conserving surgery with conventionally fractionated whole-breast radiotherapy;
- Clinicians may offer ALND for women with early-stage breast cancer with nodal metastases found in SNB specimens who will receive mastectomy; and
- Clinicians may offer SNB for women who have operable breast cancer and multicentric tumors, ductal carcinoma in situ when mastectomy is performed, prior breast and/or axillary surgery, or preoperative systemic therapy.
The expert panel also noted there are insufficient data to change the 2005 recommendation that clinicians should not perform SNB for women who have early-stage breast cancer and have:
- large or locally advanced invasive breast cancers (tumor size T3/T4);
- inflammatory breast cancer;
- ductal carcinoma in situ when breast-conserving surgery is planned; and
- pregnancy.
There remains considerable variation in the availability and use of SNB throughout the United States and across age, race and socioeconomic groups, Lyman said.
“It is commonly recommended in large community and academic hospitals and among surgeons who specialize in breast cancer, but less so in smaller institutions and among general surgeons not focused on breast cancer,” he said. “Referral to major centers or surgeons specializing in breast cancer surgery along with continued education of general surgeons in more rural settings is recommended along with efforts to reduce disparities based on age, race, and socioeconomic status.” – by Chuck Gormley
For more information:
Gary H. Lyman, MD, can be reached at Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., M3-B232, P.O. Box 19024, Seattle, WA 98109-1024.
Disclosure: The authors report no relevant financial disclosures.
Perspective
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The latest ASCO guidelines for sentinel lymph node biopsy (SLNB) in patients with early-stage breast cancer are largely unchanged from previous recommendations issued in 2014. Although most of the guidance presented is generally well adhered to — particularly where the evidence quality is high, and the strength of recommendation is strong — many surgeons have moved beyond the somewhat conservative recommendations made by the panel where evidence was felt to be insufficient to change prior recommendations.
For example, there is mounting evidence that SLNB is safe in pregnancy, particularly using technetium-99 sulfur colloid alone.
Further, although patients with T3 disease may be more likely to have axillary node metastases, SLNB seems to be as accurate in these patients as in those with T1 and T2 disease.
Although data from ACOSOG Z-0011 have largely been integrated into clinical practice, the uptake — both in terms of guidelines and practice — has not been so strong when considering other trials, such as the IBCSG 23-01 and AMAROS, which demonstrated that completion axillary node dissection may not be required in all node-positive patients, including those undergoing mastectomy. As further data emerge, however, we anticipate that these guidelines will change and surgeons will be ever-less aggressive in terms of axillary management of patients with early-stage breast cancer.
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