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 This is an original JCO publication from 2016. Please visit the JCO website to access the full article.


Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update



 Authors

Gary H. Lyman, Mark R. Somerfield, Linda D. Bosserman, Cheryl L. Perkins, Donald L. Weaver, and Armando E. Giuliano

THE BOTTOM LINE


Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Guideline Questions

How should the results of sentinel node biopsy (SNB) be used in clinical practice? What is the role of SNB in special circumstances in clinical practice? What are the potential benefits and harms associated with SNB?

Target Population

Medical oncologists, radiation oncologists, pathologists, surgeons, oncology nurses, patients/caregivers, and guideline implementers.

Target Audience

Medical oncologists, surgical oncologists, hospitalists, oncology nurses, patients, and other relevant oncologic professionals.

Methods

An Expert Panel was convened to determine whether previous recommendations remain valid, based on an updated review of evidence from the medical literature.

Recommendations

Recommendation 1. Clinicians should not recommend axillary lymph node dissection (ALND) for women with early-stage breast cancer who do not have nodal metastases (Type: evidence based; benefits outweigh harms. Evidence quality: high. Strength of recommendation: strong).

Recommendation 2.1. 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 (Type: evidence based; benefits outweigh harms. Evidence quality: high. Strength of recommendation: strong).

Recommendation 2.2. Clinicians may offer ALND for women with early-stage breast cancer with nodal metastases found in SNB specimens who will receive mastectomy (Type: evidence based; benefits outweigh harms. Evidence quality: low. Strength of recommendation: weak).

Recommendation 3. Clinicians may offer SNB for women who have operable breast cancer who have the following circumstances:

3.1. Multicentric tumors (Type: evidence based; benefits outweigh harms. Evidence quality: intermediate. Strength of recommendation: moderate).

3.2. Ductal carcinoma in situ when mastectomy is performed. (Type: informal consensus; benefits outweigh harms. Evidence quality: insufficient. Strength of recommendation: weak).

3.3. Prior breast and/or axillary surgery (Type: evidence based; benefits outweigh harms. Evidence quality: intermediate. Strength of recommendation: strong).

3.4. Preoperative/neoadjuvant systemic therapy (Type: evidence based; benefits outweigh harms. Evidence quality: intermediate. Strength of recommendation: moderate).

Recommendation 4. There are insufficient data to change the 2005 recommendation that clinicians should not perform SNB for women who have early-stage breast cancer and are in the following circumstances:

4.1. Large or locally advanced invasive breast cancers (tumor size T3/T4) (Type: informal consensus. Evidence quality: insufficient. Strength of recommendation: weak).

4.2. Inflammatory breast cancer (Type: informal consensus. Evidence quality: insufficient. Strength of recommendation: weak).

4.3. Ductal carcinoma in situ when breast-conserving surgery is planned (Type: informal consensus. Evidence quality: insufficient. Strength of recommendation: strong).

4.4. Pregnancy (Type: informal consensus. Evidence quality: insufficient. Strength of recommendation: weak).

Additional Resources

More information, including a Data Supplement with additional evidence tables, a Methodology Supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/breast-sentinel-node-biopsy-guideline and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients should have the opportunity to participate.

SUMMARY OF RECOMMENDATIONS

RecommendationEvidence Rating
Clinicians should not recommend axillary lymph node dissection (ALND) for women with early-stage breast cancer who do not have nodal metastases.

Type: evidence based; benefits outweigh harms

Evidence quality: high

Strength of recommendation: strong

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 (BCS) with conventionally fractionated whole-breast radiotherapy.

Type: evidence based; benefits outweigh harms

Evidence quality: high

Strength of recommendation: strong

Clinicians may offer ALND for women with early-stage breast cancer with nodal metastases found on SNB who will receive mastectomy

Type: evidence based; benefits outweigh harms

Evidence quality: low

Strength of recommendation: weak

Clinicians may offer SNB for women who have operable breast cancer who have the following circumstances:
Multicentric tumors

Type: evidence based; benefits outweigh harms

Evidence quality: intermediate

Strength of recommendation: moderate

Ductal carcinoma in situ (DCIS) when mastectomy is performed.

Type: informal consensus; benefits outweigh harms

Evidence quality: insufficient

Strength of recommendation: weak.

Prior breast and/or axillary surgery

Type: evidence based; benefits outweigh harms

Evidence quality: intermediate

Strength of recommendation: strong

Preoperative/neoadjuvant systemic therapy

Type: evidence based; benefits outweigh harms

Evidence quality: intermediate

Strength of recommendation: moderate

Preoperative/neoadjuvant systemic therapy

Type: evidence based; benefits outweigh harms

Evidence quality: intermediate

Strength of recommendation: moderate

There are insufficient data to change the 2005 recommendation that clinicians should not perform SNB for women who have early-stage breast cancer and are in the following circumstances:
Large or locally advanced invasive breast cancers (tumor size T3/T4)

Type: informal consensus

Evidence quality: insufficient

Strength of recommendation: weak

Inflammatory breast cancer

Type: informal consensus

Evidence quality: insufficient

Strength of recommendation: weak

DCIS when breast-conserving surgery is planned

Type: informal consensus

Evidence quality: insufficient

Strength of recommendation: strong

Pregnancy

Type: informal consensus

Evidence quality: insufficient

Strength of recommendation: weak




ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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