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Adjuvant Capecitabine for Residual HER2-Negative Breast Cancer After Neoadjuvant Chemotherapy
In a randomized trial of approximately 900 patients with HER2-negative breast cancer and residual disease after neoadjuvant chemotherapy, patients in the adjuvant capecitabine group, compared with placebo, had higher rates of five-year disease-free survival (74 versus 68 percent) and overall survival (89 versus 84 percent). Subgroup analyses suggested that these findings were driven primarily by outcomes in patients with triple-negative disease. Toxicities were higher in patients receiving capecitabine, including diarrhea, neutropenia, and hand-foot syndrome. Given these results, we now suggest capecitabine for patients with residual HER2-negative breast cancer after neoadjuvant therapy, though observation is also acceptable, given the increased toxicities associated with adjuvant capecitabine.
Risk of Colon Cancer in Patients With Diverticulitis
The utility of routine colonoscopy after acute diverticulitis is debated. An analysis of data from a Danish registry showed that patients hospitalized for diverticulitis were twice as likely to develop colon cancer over the 18-year study period as those without diverticulitis, and over 50 percent of colon cancers were diagnosed within one year of diagnosis of diverticulitis. This study underscores the importance of endoscopic surveillance in patients with diverticular disease and supports our recommendation for performing a colonoscopy after the complete resolution of an episode of acute diverticulitis in patients who have not had a colonoscopy within a year.
Sentinel Lymph Node Biopsy in Endometrial Cancer
Sentinel lymph node biopsy for staging endometrial carcinoma is increasingly performed instead of selective or extended nodal dissection. In the largest multicenter prospective study of the procedure in over 300 women with clinical stage I endometrial carcinoma, successful mapping of at least one sentinel lymph node was achieved in 86 percent and the sensitivity of the sentinel lymph node was 97 percent. Nevertheless, we believe further study is needed before sentinel lymph node biopsy is established as a reasonable alternative to full pelvic lymphadenectomy in endometrial carcinoma.
Guideline on Use of Molecular Markers in Colorectal Cancer
The prognostic value of a wide variety of potentially clinically applicable molecular markers has been extensively studied in colorectal cancer (CRC). An updated multisociety United States guideline recommends testing for DNA mismatch repair protein (MMR) status to identify patients at high risk for Lynch syndrome, expanded or extended RAS testing for patients being considered for therapy targeting the epidermal growth factor receptor (EGFR), and BRAF V600 mutational analysis for deficient MMR tumors with loss of MLH1 expression to evaluate for Lynch syndrome risk. They also concluded that there was insufficient evidence to use BRAF mutational status as a predictive molecular biomarker for response to anti-EGFR therapies. However, this is a controversial area. UpToDate recommends not using EGFR inhibitors in patients with a tumoral BRAF V600E mutation.
Laparoscopic Interval Debulking After Neoadjuvant Chemotherapy for Ovarian Cancer
Women with stage IIIC or IV ovarian cancer and unresectable disease may be candidates for neoadjuvant chemotherapy (NACT) followed by interval debulking, typically performed with laparotomy. Results of a large retrospective study suggest that laparoscopy could be a minimally invasive option for such debulking. Compared with laparotomy, laparoscopy was associated with similar three-year overall survival rates (47.5 versus 52.6 percent), similar suboptimal debulking rates (20.0 versus 22.6 percent), a shorter hospital stay by one day, and similar 30-day readmission rates. Further study is needed to evaluate whether short-term morbidity is reduced with use of laparoscopy.
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