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Adjuvant T-DM1 for HER2-Positive Early Breast Cancer
Women with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer typically receive chemotherapy and trastuzumab, either prior to or after surgery, with trastuzumab continued as adjuvant therapy to complete a year of treatment. However, in a randomized trial of women with HER2-positive early breast cancer with residual disease after neoadjuvant therapy, adjuvant treatment with the antibody-drug conjugate ado-trastuzumab emtansine (T-DM1) improved three-year invasive disease-free survival compared with trastuzumab (88 versus 77 percent). Based on these results, we now recommend T-DM1 in the adjuvant setting for women with HER2-positive early breast cancer who have residual disease after neoadjuvant therapy, rather than trastuzumab.
Screening for Pancreatic Cancer in High-Risk Individuals
Guidelines suggest screening for pancreatic cancer in selected patients with hereditary pancreatitis or known mutations in specific inherited cancer susceptibility syndromes. However, pancreatic cancer screening has not been demonstrated to improve survival. A cohort study reported results of 16-year follow-up on 354 high-risk individuals who underwent periodic surveillance with endoscopic ultrasound (EUS), magnetic resonance imaging (MRI), and/or computed tomography (CT). A pancreatic lesion with worrisome features was detected in nearly 20 percent, and one-third of those lesions were neoplastic. Of the 14 pancreatic duct adenocarcinomas detected during the study, 10 were asymptomatic and detected by surveillance, and nine of these were resectable, early-stage cancers. The overall three-year survival rate was higher for the pancreatic cancers diagnosed during surveillance compared with the four detected outside of surveillance. Large prospective studies are needed to validate the potential benefits of pancreatic cancer screening on survival.
Lateral Compartment Lymphadenectomy for Low Rectal Cancer
Lateral lymphadenectomy (LLN) is not a standard procedure for patients with low rectal cancer. In a multicenter retrospective study of over 1,200 patients with cT3/4 rectal cancer below the peritoneal reflection, patients with lateral lymph nodes with a short axis ≥7 mm on initial imaging who underwent total mesorectal excision, chemoradiotherapy, plus LLN had a lower five-year recurrence rate than those who did not undergo LLN (6 versus 20 percent). Because it remains unclear whether enlarged lymph nodes in the lateral compartment are better addressed by more aggressive radiation treatment or by surgical removal, surgeons should follow their local institutional protocol for low rectal cancers.
Treating Isolated Biochemical Recurrence After Prostatectomy for Prostate Cancer
For men with an isolated biochemical recurrence after radical prostatectomy for localized prostate cancer, salvage prostate bed radiation therapy (RT) improves survival; the benefits of including the pelvic lymph nodes in the radiation field have been controversial. An interim analysis of the RTOG 0534 randomized trial in men with a post-prostatectomy biochemical recurrence, reported at the 2018 ASTRO meeting, found that the addition of short-term androgen deprivation therapy (ADT) to prostate bed RT improved five-year freedom from progression (FFP); the addition of pelvic lymph node RT improved FFP compared with prostate bed RT plus short-term ADT. Treatment-related acute gastrointestinal and bone marrow toxicity were slightly higher when pelvic nodal irradiation was added to ADT and prostate bed RT. Based on these preliminary data, while we still consider prostate bed RT with short-term ADT to represent the current standard of care, the option of adding pelvic nodal RT should be discussed with men for shared decision making, with full disclosure of the uncertainty of benefits and potential harms.
Aspirin Use and Risk of Ovarian Cancer
The effect of analgesics on risk of ovarian cancer has been extensively studied, with conflicting results. Now, the Nurses' Health study, a prospective cohort study including more than 200,000 women with 1,054 incidence cases of ovarian cancer, reports a decrease in ovarian cancer incidence associated with current regular use of low-dose (≤100 mg) but not standard-dose (325 mg) aspirin or acetaminophen. Heavy, long-term use of nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with a trend toward increased ovarian cancer incidence. Women considering low aspirin use for prevention of cardiovascular disease can consider the possible reduction in ovarian cancer, but this should not be a major factor in decision-making, given the low quality of available data.
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