Management of Regional Nodes in the Treatment of Breast Cancer: An American Radium Society Appropriate Us Criteria Panel for Breast Cancer Systematic Review and Guideline

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Conference Proceeding

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International Journal of Radiation Oncology Biology Physics


Background: The management of regional nodes in breast cancer patients is a complex and evolving area of significant clinical impact. Numerous recent randomized trials and other studies have reported improved survival outcomes associated with the inclusion of regional nodal irradiation in patients with node positive breast cancer or even high risk node negative breast cancer. The selection of patients for extent of axillary surgery has also been the subject of numerous randomized trials with a resulting reduction in the use of axillary dissection in many populations. Selection of systemic agent sis increasingly driven by molecular assays rather than clinicopathologic features such as number of positive nodes. Treatment of nodal volumes can also increase chronic toxicities such as lymphedema and reduced range of motion, so would ideally be used in patients who truly benefit. Many controversies remain, including optimal patient selection in the intermediate risk patients especially after mastectomy and after neoadjuvant chemotherapy, which nodal volumes to include in which patients, and the optimal dose fractionation. Several ongoing randomized trials are examining the role of nodal treatment after neoadjuvant chemotherapy and dosing regimens. Objectives: Due to the emerging body of data and the evolving standards, the ARS Breast Cancer AUC panel has launched a new topic on the management of regional nodes in breast cancer treatment. Our goal is to provide guidance for the multidisciplinary decision making regarding extent of surgery, use of nodal radiation and selection of sequencing of systemic agents as indicated by molecular subtyping and other genomic assays.

Methods: A systematic literature review of the randomized controlled trials, meta-analyses and other prospective or population based studies was conducted to identify the studies published since January 2000. An evidence table was developed and studies ranked by study type, findings and level of evidence.

Results: Topics for evidence-based guideline development include use of sentinel node lymphadenectomy for pathologic node negative and selection of patients for further axillary dissection with positive sentinel nodes, regional nodal irradiation instead of axillary dissection, regional node irradiation after neoadjuvant chemotherapy, design of radiation treatment parameters including target volumes, radiation fields and techniques and impact of genomic assays on selection of therapy. A review article and executive summary along with variants of clinical scenarios is under development to provide a guideline to clinicians regarding these patient populations. Variants are scored by consensus mythology to provide strength of evidence and consensus.

Conclusions: The management of lymph nodes in early stage breast cancer patients at intermediate risk for recurrence involves several areas of controversy and evolving practice which this evidence-based appropriate use criteria project addresses in order to provide practical guidance to the multidisciplinary oncology community.





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