ASCO Updates Guideline for Sentinel Node Biopsy in Early Stage Breast Cancer; Evidence Supports Use of This Less Invasive Diagnostic in More Patients

For immediate release
March 24, 2014

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Kirsten Goldberg
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ALEXANDRIA, VA -- The American Society of Clinical Oncology (ASCO) has issued new recommendations for the use of sentinel lymph node biopsy in patients with early stage breast cancer. The guideline, "Sentinel Lymph Node Biopsy for Patients with Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update," was published today in the Journal of Clinical Oncology.

Since the Society issued its initial guideline in 2005, evidence from clinical trials now supports using this less invasive diagnostic technique in a larger group of patients. This updated guideline will enable more women with early stage breast cancer to avoid the more invasive axillary lymph node dissection, which has a greater risk of complications.

"The updated guideline incorporates new evidence from more recent studies -- nine randomized controlled trials and 13 cohort studies since 2005," said Armando Giuliano, MD, FACS, co-chair of ASCO's Expert Panel that updated the guideline. "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."

Axillary lymph node dissection (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 can cause long-term side effects including pain and numbness in the arm and lymphedema, a condition that causes swelling because of a build-up of lymph fluid.

Sentinel node biopsy (SNB) has been an important advancement in improving the quality of life of breast cancer patients. When cancer spreads through the lymphatic system, the lymph node or group of lymph nodes the cancer reaches first is called the sentinel node. 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 will not have cancer. The procedure can cause side effects, but they are less common than with ALND.

The guideline updates three recommendations based on evidence from randomized controlled trials:

• Women without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND).
• Most women with 1 to 2 metastatic SLNs planning to receive breast conserving surgery with whole breast radiotherapy should not undergo ALND.
• Women with SLN metastases who will receive mastectomy may be offered ALND.

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

• Women with operable breast cancer and multicentric tumors, and/or DCIS who will have mastectomy, and/or had prior breast and/or axillary surgery, and/or had preoperative/neoadjuvant systemic therapy may be offered sentinel lymph node biopsy (SNB).
• Women who have large or locally advanced invasive breast cancers (tumor size T3/T4), and/or inflammatory breast cancer, and/or DCIS, when breast-conserving surgery is planned, and/or are pregnant should not receive SNB.

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

"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," said Gary Lyman, MD, MPH, FASCO, 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."

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 Medline and based its recommendations on review of the evidence. It also includes an appendix on pathology.

More information on the new guideline and clinical tools and resources can be found at www.asco.org/guidelines. Patient information is available at www.cancer.net/recommendations.

To view the guideline, please click here.

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About ASCO: 

Founded in 1964, the American Society of Clinical Oncology (ASCO) is the world’s leading professional organization representing physicians who care for people with cancer. With more than 35,000 members, ASCO is committed to improving cancer care through scientific meetings, educational programs and peer-reviewed journals. ASCO is supported by its affiliate organization, the Conquer Cancer Foundation, which funds groundbreaking research and programs that make a tangible difference in the lives of people with cancer. For ASCO information and resources, visit asco.org. Patient-oriented cancer information is available at Cancer.Net.