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Surgical Margin in Breast Conserving Surgery for Ductal Carcinoma in Situ
For women undergoing breast conserving therapy for ductal carcinoma in situ (DCIS), surgical resection margins have a significant impact on local recurrence, but the optimal margin has been controversial. A meta-analysis found a 2 mm margin was associated with a twofold reduction in local recurrence rates compared with a positive margin, and equivalent recurrence rates compared with wider margins. A multidisciplinary consensus guideline advises that 2 mm be the standard for an adequate margin in DCIS treated with breast conserving surgery followed by whole breast irradiation. Clinical judgment is advised when determining whether patients with a negative but <2 mm margin require re-excision.
Fecal Immunochemical Testing for Colorectal Cancer Screening
Multiple test strategies are available for screening in people with average risk for colorectal cancer (CRC). Annual stool testing for occult blood using a guaiac reagent (gFOBT) has been widely implemented and is one of the screening strategies endorsed by the US Preventive Services Task Force. Fecal immunochemical testing (FIT) is another option and has the potential advantages of better test performance (improved sensitivity for CRC and advanced adenomas) and better patient adherence (one stool sample, no diet restrictions) compared with gFOBT. The US Multi-Society Task Force has published consensus guidelines recommending FIT over gFOBT when occult blood stool testing is elected for CRC screening.
First-line Chemotherapy for Advanced Esophagogastric Cancer
There is no globally accepted first-line chemotherapy regimen for advanced, HER2-negative esophagogastric cancer. A network meta-analysis of 17 different chemotherapy regimens concluded that, based upon efficacy and toxicity, a fluoropyrimidine doublet regimen with oxaliplatin, irinotecan, or a taxane was preferred over a fluoropyrimidine/cisplatin doublet or anthracycline or docetaxel-containing triple therapy. For most patients without a clinical trial option, we suggest a platinum/fluoropyrimidine doublet over triplet therapy. We generally prefer oxaliplatin plus a fluoropyrimidine but still consider a cisplatin/fluoropyrimidine doublet to be a reasonable alternative, given the lack of a phase III trial showing inferior results for a cisplatin versus oxaliplatin-containing regimen.
Chemotherapy for Mediastinal Nonseminomatous Germ Cell Tumors
Cisplatin-based chemotherapy is the primary treatment for patients with mediastinal nonseminomatous germ cell tumors (NSGCTs). However, many patients require subsequent surgical resection of a residual thoracic mass. In a retrospective analysis, the combination of bleomycin, etoposide, and cisplatin (BEP) was associated with significantly more severe pulmonary toxicity and treatment-related deaths than the combination of etoposide, ifosfamide, and cisplatin (VIP). In the absence of randomized trials, we recommend VIP rather than BEP for the initial chemotherapy of mediastinal NSGCTs.
Risk of Preterm Delivery Following Loop Electrosurgical Excision Procedure (LEEP)
Studies have consistently found an increased risk for preterm delivery in pregnancies conceived after cold knife conization, but data are mixed regarding the risk with laser conization and loop electrosurgical excision procedure (LEEP). In the largest study of pregnancy outcomes after treatment for cervical intraepithelial neoplasia (CIN), a Norwegian registry study of almost 10,000 births confirmed that prior treatment for CIN was associated with an increased risk of preterm birth compared with no prior treatment. The strongest associations were for cold knife and laser conization, but a small increase in risk was also observed for LEEP. Women with CIN 2,3 who plan future childbearing should be counseled about the risks and benefits of both treatment and observation.
Updated MASCC/ESMO Guidelines for Nausea and Emesis Related to Cancer Treatment
Updated guidelines for prevention and management of cancer therapy-associated nausea and vomiting are available from the Multinational Association of Supportive Care in Cancer and the European Society of Medical Oncology, the consensus panel also provides guidance on the use of prophylactic antiemetics in patients undergoing radiation therapy.