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Long-Term Outcomes of Women With Breast Cancer and Sentinel Node Metastasis
The American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial established the safety of omitting routine axillary lymph node dissection (ALND) in women with early-stage breast cancer, no palpable axillary adenopathy, and one or two metastatic sentinel lymph nodes. Now, extended follow-up to about 10 years continues to show that both overall survival and disease-free survival after sentinel lymph node dissection (SLND) alone are noninferior to ALND. These results support Z0011's early conclusion that women undergoing breast conserving surgery and SLND do not require routine ALND.
No Incremental Benefit From Robotically Assisted Radical Nephrectomy
Radical nephrectomy is increasingly performed with robotic assistance, despite a lack of evidence of incremental benefit. In a study including over 23,000 patients in a United States database who underwent radical nephrectomy, robotic radical nephrectomy was associated with longer operative time and higher hospital costs than the conventional laparoscopic approach, without lowering the rate of overall or major complications. We suggest conventional laparoscopic surgery for radical nephrectomy; however, robotic assistance may have a role in partial nephrectomy.
Misuse of Prescribed Opioids
Misuse of prescribed opioid drugs is a major source of escalating rates of opioid use disorder and opioid overdose in the United States. The 2015 National Survey on Drug Use and Health estimated that among the 92 million US adults prescribed opioid drugs in the prior year, almost 13 percent reported prescription opioid misuse, and 2 percent reported having a prescription opioid use disorder. Misuse reported by study subjects included taking higher or more frequent doses than prescribed and buying or using opioids prescribed to someone else.
Adjuvant Therapy of Cutaneous Melanoma
Patients at high risk for recurrence after definitive surgical resection of cutaneous melanoma are candidates for adjuvant therapy. In a phase III trial, nivolumab increased relapse-free survival compared with ipilimumab. In another phase III trial, dabrafenib plus trametinib increased relapse-free and overall survival compared with placebo in patients with a BRAF V600 mutation. Neither regimen is currently approved in the adjuvant setting, but enrollment of high-risk patients in formal clinical trials should be considered whenever feasible.
Incidence of Endocrinopathies With Checkpoint Inhibitor Immunotherapy
Immunotherapy of cancer with checkpoint inhibitors is associated with multiple immune-related adverse events, including hypothyroidism, hyperthyroidism, hypophysitis, primary adrenal insufficiency, and type 1 diabetes. In a systematic review of 38 randomized trials, thyroid dysfunction was the most common endocrinopathy. The combination of nivolumab plus ipilimumab was associated with the highest incidence of hypothyroidism, while monotherapy with a PD-1 inhibitor (nivolumab, pembrolizumab) had the lowest incidence.
New ASCO Guideline Aims to Improve Communication Skills
The way in which serious news is conveyed can substantially influence the emotional response to the news, beliefs and attitudes toward the medical staff, and how patients view their future. While there are no consistent findings from randomized interventional studies that show better patient outcomes after modifying communication skills to deliver serious news, a number of studies have shown that clinician communication skills can be improved by training. A 2017 guideline from the American Society of Clinical Oncology (ASCO) recommends communication skills training for oncologists and presents best practices for core communication skills when clinicians are communicating with patients and their loved ones about goals of care, prognosis, treatment options, and end of life care.
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