New Guidelines Might Limit Need for Lymph Node Removal for Breast Cancer

MONDAY, March 24, 2014 (HealthDay News) -- Biopsies of so-called "sentinel" lymph nodes under the arms should become more widespread among breast cancer patients, according to updated guidelines from the American Society of Clinical Oncology (ASCO).

The group, which represents cancer specialists, said the new recommendations should also restrict the number of women who will require further removal of multiple nodes after biopsy, cutting down on painful side effects.

In sentinel lymph node biopsy, a few lymph nodes are removed and checked for signs of cancer -- hence the name "sentinel." Usually, if these lymph nodes have no cancer, it means the remaining, unchecked lymph nodes should also be cancer-free.

The new ASCO recommendations expand eligibility for sentinel node biopsy and will reduce the number of patients who undergo a more invasive procedure called axillary -- underarm -- lymph node dissection, which carries a higher risk of complications, the group said.

In axillary lymph node dissection, most lymph nodes under the arm on the same side as the breast tumor are removed and examined for cancer. This procedure can cause long-term side effects such as pain and numbness in the arm and swelling due to a build-up of lymph fluid.

The new guidelines state that for women whose sentinel lymph nodes show no signs of cancer, removal of more underarm lymph nodes is not recommended.

The guidelines also addressed the case of women who undergo lumpectomy instead of full mastectomy and are also scheduled for whole-breast radiation therapy to help "mop up" residual cancer. If these patients have signs of cancer in only one or two sentinel lymph nodes upon biopsy, they too may opt to avoid further node removal, the ASCO experts said.

Women who have undergone mastectomy but show signs of cancer's spread in sentinel lymph nodes should be offered further node removal, the guidelines reaffirmed.

The ASCO also said women who are diagnosed with certain breast cancers while pregnant can skip sentinel node biopsy.

The ASCO issued initial guidelines on sentinel node biopsy in 2005. The new guidelines, published March 24 in the Journal of Clinical Oncology, are based on the findings of a panel of experts who reviewed studies published between 2004 and 2013.

"The updated guideline incorporates new evidence from more recent studies -- nine randomized controlled trials and 13 cohort studies since 2005," panel co-chairman Dr. Armando Giuliano said in an ASCO news release.

"Based on these studies, we're saying more patients can safely get sentinel node biopsy without axillary lymph node [removal]," he said. "These guidelines help determine for whom sentinel node biopsy is appropriate."

Panel co-chairman Dr. Gary Lyman said, "We strongly encourage patients to talk with their surgeon and other members of their multidisciplinary team to understand their options and make sure everybody is on the same page."

"The most critical determinant of breast cancer prognosis is still the presence and extent of lymph node involvement," he said. "Therefore, the lymph nodes need to be evaluated so we can understand the extent of the disease."

Two breast cancer specialists welcomed the new guidelines.

"Over the past few years, there has been a movement to limit the amount of axillary [lymph node] surgery in patients undergoing breast conservation," said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City.

Bernik said the new guidelines are important because some doctors have been reluctant to move away from further underarm node removal when a patient has even one affected sentinel node. "This update will give surgeons the confidence to tell patients that a sentinel lymph node biopsy may be enough, even if there is evidence of spread, in patients undergoing [lumpectomy]," Bernik said.

"However, it is still important for surgeons to discuss the pros and cons with a patient, as not all [real-world] patients fit the study criteria," she said. "Furthermore, it needs to be stressed that the more limited surgery does not apply to women undergoing mastectomies."

Dr. Debra Patt is the medical director of an expert panel that assesses cancer care guidelines for the US Oncology Network. She said she was "thrilled" at the new ASCO guidelines because they seem to echo the results of recent studies.

"In 2010, a study presented at the ASCO annual meeting showed that women undergoing breast-conservation surgery with clinically node-negative small breast cancers could safely avoid removing all the lymph nodes from under the arm in most cases," Patt said. "There has been greater variance in treatment patterns in my community practice, and I believe these updated guidelines will direct practitioners to evidence-based patient care."

-- Robert Preidt
Copyright © 2014 HealthDay. All rights reserved. SOURCES: Stephanie Bernik, M.D., chief, surgical oncology, Lenox Hill Hospital, New York City; Debra Patt, M.D., medical director, Pathways Task Force and Healthcare Informatics, US Oncology Network; American Society of Clinical Oncology, news release, March 24, 2014

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Current Colon Cancer Screening Guidelines Might Miss Some Patients

FRIDAY, Oct. 25 (HealthDay News) -- Current U.S. colon cancer screening guidelines may result in 10 percent of colon cancers being missed in people with a family history of colon polyps that can lead to cancer, a new study suggests.

"The biggest surprise was the percentage of missed cancers under the current guidelines. We figured there would be a few percent, but 10 percent is a large number," study author Dr. N. Jewel Samadder, of the Huntsman Cancer Institute at the University of Utah, said in a university news release.

Colorectal cancer is the third most common cancer in the United States and the second deadliest.

Samadder's team looked at data from nearly 127,000 people, aged 50- to 80, who underwent colonoscopy in Utah between 1995 and 2009. They found that first-degree relatives -- parents, siblings, children -- of people with adenomas (polyps linked to cancer) or advanced adenomas had a 35 percent to 70 percent increased risk of developing colon cancer than relatives of patients without these growths.

Second-degree relatives (aunts, uncles, grandparents) and third-degree relatives (cousins, nieces, nephews, great-grandparents) of people with adenomas were also at increased risk for colon cancer, according to the study published online Oct. 25 in the journal Cancer.

"We expected to see increased risk in first-degree relatives, but we weren't sure the risk would also be higher for more distant relatives in multiple generations," Samadder said.

Current national guidelines for colon cancer screening recommend colonoscopy every 10 years starting at age 50 for the general population. But first-degree relatives of people diagnosed with either colorectal cancer or advanced adenomas before age 60 should have a colonoscopy every five years beginning at age 40, according to the guidelines.

However, screening recommendations for second- and third-degree relatives of people diagnosed before age 60 are the same as for the general public.

So, the new findings "raise the issue of whether some level of more aggressive screening should be considered, not only for first-degree relatives of patients with polyps diagnosed at or below age 60, but also for those first-degree relatives of patients diagnosed above age 60," Samadder said.

One expert not connected to the study said the findings may be important, but it's often difficult to assess a patient's family history when it comes to colon cancer.

"This information is important not only to specialists who treat colon and rectal and cancer but all primary care providers who recommend screening programs for their patients," said Dr. Jerald Wishner, director of colorectal surgery at Northern Westchester Hospital in Mount KIsco, NY.

However, he added that, "It will be difficult to apply this information in everyday clinical practice. I regularly see patients who know their relatives have had surgery for cancer don't know the type. Finding out if their relatives have had adenomas or advanced adenomas will be very difficult. This will be further complicated as we seek information about second or third degree relatives."

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCES: Jerald Wishner, M.D., director, colorectal surgery, Northern Westchester Hospital, Mount Kisco, N.Y; University of Utah, news release, Oct. 22, 2013

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New Guidelines Advocate Earlier HIV Treatment (CME/CE)

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Published: Jul 1, 2013

By Ed Susman, Contributing Writer, MedPage TodayReviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse PlannerNote that these new World Health Organization guidelines recommend treatment for HIV when CD4 counts fall below 500 cells/mm3.In addition, the guidelines recommend treatment of all those who are coinfected with HIV and either hepatitis B or tuberculosis.

KUALA LUMPUR -- New international guidelines suggest that people diagnosed with human immunodeficiency virus (HIV) be treated earlier in the course of the disease -- effectively making another 9.2 million people eligible for antiretroviral therapy, researchers said here.

Currently in the underdeveloped world, where HIV has devastated many nations, 9.7 million people out of an estimated 16.7 million who should be treated receive effective antiretroviral therapy, said Gundo Weiler, MD, PhD, medical and health policy adviser of the National German AIDS Organization in Berlin. But the impact of the new World Health Organization (WHO) guidelines will increase the number of patients who need to be treated to 25.9 million.

The major increase comes from earlier treatment -- commencing highly active antiretroviral therapy (HAART) when infected persons' CD4-positive cell counts drop below 500 cells/mm3, Weiler, who helped write the recommendations, said at the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. The previous guidelines suggested treating patients once those immune system markers fell below 350 cells/mm3.

Weiler said the 2013 WHO guidelines would result in 3 million deaths due to HIV being avoided between 2013 and 2025 when compared with 2010 guidelines. The implementation of the guidelines also would reduce new HIV infections by 36% by 2025 compared with projections using the 2010 guidelines.

The change in definition of when to commence treatment adds 3.9 million persons to the "should be in treatment" statistics. The new guidelines also expand the use of antiretroviral therapy in children. Under the old guidelines, 1.2 million children needed to be in treatment; the new guidelines expand that to 2.6 million children.

The new guidelines suggests that all HIV-positive pregnant women, regardless of CD4 count, be placed on antiretroviral therapy -- adding 700,000 people to those needing treatment.

The new guidelines also advocate immediate treatment with HAART therapy for those 3.2 million people now coinfected with tuberculosis or hepatitis B infection.

All told, the new guidelines increase the numbers of patients needing HAART by 9.2 million.

Weiler said that by increasing contributions from governments and other agencies by 10% a year, it will be possible to have those patients under treatment by 2025. But because treatment reduces infections, after 2025, the number of patients living with HIV and the number of people on treatment will begin to merge.

"Generally, in the U.S. and Canada we are already using these guidelines to treat our patients," Julio Montaner, MD, professor of medicine at the University of British Columbia, Vancouver, told MedPage Today.

"What these guidelines will do, however, is to convince doctors who are on the fence about where to begin treatment to start treating their patients earlier," Montaner said.

He also said that in Europe -- especially in countries that are experiencing economic crises -- the guidelines will help convince those health providers to initiate HAART therapy earlier. Montaner did not participate in the WHO guideline-writing process.

The new guidelines recommend: Treating adults, adolescents, and older children earlier -- starting antiretroviral therapy in all individuals with a CD4 cell count of 500 cells/mm3 or less and giving priority to individuals with severe or advanced HIV disease and those with a CD4 cell count of 350 cells/mm3 of less.Starting antiretroviral therapy at any CD4 cell count for certain populations with HIV, including people with active tuberculosis disease, people with hepatitis B coinfection with severe chronic liver disease, HIV-positive partners in serodiscordant couples, pregnant and breastfeeding women, and children younger than 5 years of age.A new preferred first-line antiretroviral regimen harmonized for adults, pregnant and breastfeeding women and children ages 3 or older. That first-line therapy should be a fixed-dose combination of tenofovir plus lamivudine or emtricitabine plus efavirenz.Support to actively accelerate the phasing out of stavudine (d4T) in first-line regimens for adults and adolescents.

The guidelines also include new recommendations for testing for HIV.

Montaner reported commercial relationships with Abbott, Gilead Sciences, GlaxoSmithKline, and Merck.

Weiler reported no disclosures.

Primary source: International Aids Society
Source reference:
World Health Organization "Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV Infection" IAS 2013.

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