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CME: Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer

CME: Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer
Author Information (click to view)

Gary H. Lyman, MD, MPH

Co-Director, Hutchinson Institute for Cancer Outcomes Research
Division of Public Health Sciences
Fred Hutchinson Cancer Research Center
Professor of Medicine
University of Washington, Seattle

Gary H. Lyman, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Cite key recommendations made in the American Society of Clinical Oncology’s 2014 update to the clinical practice guideline for sentinel lymph node biopsy for patients with early-stage breast cancer.
  2. Identify areas identified by the American Society of Clinical Oncology for which more research is needed to enhance care for women with early-stage breast cancer.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwmay4.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria- Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

Gary H. Lyman, MD, MPH
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Gary H. Lyman, MD, MPH (click to view)

Gary H. Lyman, MD, MPH

Co-Director, Hutchinson Institute for Cancer Outcomes Research
Division of Public Health Sciences
Fred Hutchinson Cancer Research Center
Professor of Medicine
University of Washington, Seattle

Gary H. Lyman, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Updated recommendations have been issued for the use of sentinel lymph node biopsy in patients with early-stage breast cancer. The update will enable some women with early-stage disease to avoid more invasive procedures and their associated higher risk of complications.
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In 2005, the American Society of Clinical Oncology (ASCO) first published evidence-based clinical practice guidelines for using sentinel node biopsy (SNB) in patients with early-stage breast cancer. In 2014, these guidelines were updated and published in the Journal of Clinical Oncology. “Since publication of the original guidelines, several new randomized trial results and additional cohort studies have become available,” says Gary H. Lyman, MD, MPH, who co-chaired the ASCO expert panels for both versions of the guidelines. “We now have more evidence from clinical trials supporting the use of SNB as a less invasive cancer-staging technique for a larger group of patients.”

Developing the Guidelines

To develop the guideline update, ASCO convened experts in medical oncology, pathology, radiation oncology, surgical oncology, guideline implementation, and patient advocacy. A systematic review of the literature published from February 2004 to January 2013 in Medline was conducted. The subsequent recommendations were based on a review of the evidence. The update also includes an appendix on technical issues related to pathology.

Lymph-Node-Breast-Cancer-Callout

The ASCO guideline summarizes the updated literature search and analyzes new data related to the recommendations since the last systematic review. The update incorporates new evidence from more recent studies—including nine randomized controlled trials and 13 cohort studies—since 2005. Based on the results of these studies, more patients can now safely undergo SNB without axillary lymph node dissection (ALND).

“The guidelines can help clinicians determine for whom SNB is appropriate,” says Dr. Lyman. “This may enable more women with early stage breast cancer to avoid ALND, which is more invasive and is associated with a greater risk of complications.” ALND can cause a number of long-term side effects, such as pain and numbness in the arm and lymphedema. SNB is less invasive because only a few lymph nodes are removed and examined for signs of cancer.

Highlighting Key Updates

The guideline updates three key recommendations based on evidence from randomized controlled trials, according to Dr. Lyman (Table). “First, women without sentinel lymph node (SLN) metastases should not receive ALND. This can improve quality of life for women because it reduces their risk for lymphedema, infection, and vascular problems. Second, most women with one or two metastatic SLNs planning to receive breast conserving surgery with whole breast radiotherapy are not recommended to undergo ALND. Third, women with SLN metastases who will undergo mastectomy may be offered ALND.”

The guideline also updated two sets of recommendations based on cohort studies and/or informal consensus. SNB may be offered to women with multi-centric tumors as well as those with ductal carcinoma in situ (DCIS) who will have mastectomy. It can also be offered to those who had prior breast and/or axillary surgery and to those who had preoperative neoadjuvant systemic therapy. SNB is not recommended for women who have large or locally advanced invasive breast cancers (tumor size T3 or T4), inflammatory breast cancer, DCIS when breast-conserving surgery is planned, or in patients who are pregnant. The ASCO committee noted that evidence was insufficient to update previous recommendations in some cases.

Implementation & Research Needs

ASCO recommends that medical oncologists, surgical oncologists, radiation oncologists, and other care team members of cancer centers consider factors that may influence how the guideline update is implemented. Programs with cancer tumor boards or continuing medical education activities are encouraged to distribute and stimulate discussion of the guideline update. Dr. Lyman says these efforts may speed the sharing of the update and stimulate coordinated multidisciplinary care decisions. “We strongly encourage patients to talk with their surgeons and other members of their multidisciplinary team to understand their options and make sure all parties are on the same page,” he says. These discussions may also increase how quickly new studies and guideline updates are considered so that quality of care can be further improved.

Dr. Lyman says that more research is needed to enhance care for women with early-stage breast cancer. “We need more data to develop or improve recommendations related to several categories of patients in special circumstances,” he says. “This includes patients with very large tumors, those who are pregnant, and those who receive neoadjuvant systemic therapy.” ASCO outlines several other areas of research that should be explored in the future. Dr. Lyman notes that this research has the potential to inform medical decisions and improve cancer care so that all patients have the opportunity to receive the best available care for their specific situation.

Readings & Resources (click to view)

Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Onc. 2014 Mar 24 [Epub ahead of print]. Available at: http://jco.ascopubs.org/content/early/2014/03/18/JCO.2013.54.1177.full.pdf+html.

Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Onc. 2005;23:7703-7720.

Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305:569-575.

Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC trial. J Natl Cancer Inst. 2006;98:599-609.

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