Over the past several decades, there has been a welcome trend towards less extreme surgery for women with breast cancer. The trend has continued with recently published data about axillary node dissection.
Historically, the rationale for complete axillary lymph node (ALN) dissection was detection and removal of metastases in the ALNs, a result that has important prognostic and treatment implications. But full axillary lymph node dissection (ALND) following sentinel lymph node (SLN) sampling appears to be headed toward becoming a practice of the past.-- and avoidance of ALND should result in fewer surgical complications (e.g., lymphedema, seroma, infection, and pain), increased preservation of shoulder mobility (http://journals.lww.com/
In a recently published report of the ACOSOG Z011 Phase 3 clinical trial of patients with limited SLN metastatic breast cancer conducted from May 1999 to December 2004 at 115 sites in the U.S., Guiliano and colleagues demonstrated that ALND after SLN dissection (SLND) is unnecessary for good local control and excellent survival outcomes
(http://jama.ama-assn.org/
Almost 900 patients with early-stage invasive breast cancer who were enrolled in the trial from May 1999 to December 2004 were randomized to undergo lumpectomy, ALND (excision of ≥10 nodes), and tangential whole-breast radiation therapy (TWBRT); or lumpectomy, SLND, and TWBRT. Use of adjuvant systemic therapy (endocrine therapy and/or chemotherapy) was at the discretion of the treating medical oncologist. Approximately 96% of the ALND-treated patients and 97% of the SLND-treated patients received adjuvant systemic therapy. Median follow-up was 6.3 years.
Few recurrences occurred in the axillary nodes of patients in either group. No differences were seen in the low incidence of local and regional recurrences in the patient groups. Furthermore, patients in both groups experienced similar rates of overall survival (OS) and disease-free survival (DFS). Five-year OS was 91.8% and 92.5% in the ALND and SLND groups, respectively. Five-year DFS was 82.2% and 83.9% in patients who received ALND versus SLND.
Thus, for patients who have good prognostic indicators for breast cancers that are treated with a combination of lumpectomy, radiation therapy, and systemic therapy, good clinical outcomes may be obtained without surgical excision of involved axillary nodes. This important finding confirms the efficacy of breast-conserving surgery with adjuvant therapy, representing excellent news for women with breast cancer. Each year, thousands of women newly diagnosed with early-stage breast cancer may benefit from the high survival rates and improved quality of life provided by multi-modality therapy involving conservative surgery.
Shedding light on vitamin D & CLL prognosis
Correcting inadequate levels of vitamin D makes sense in treatment of osteoporosis, but what about cancer?
A recent article on vitamin D insufficiency and inferior prognosis of chronic lymphocytic leukemia (CLL) by Shanafelt and colleagues (http://bloodjournal.
Approximately 30.5% (119/390) of newly diagnosed CLL patients and almost 40% (61/153) of previously untreated CLL patients in the study were deficient in vitamin D. Following a median of 3 and 9.9 years of follow-up, respectively, the vitamin D-deficient patients in both the newly diagnosed CLL group and the CLL validation group experienced shorter time-to-treatment (TTT) and overall survival (OS).
In this provocative study, vitamin D insufficiency was associated with poorer prognosis for TTT and OS, even in early-stage CLL patients managed by a watch-and-wait approach.Based on analysis of data from all patients, adjusting for age, gender, Rai stage, status of various markers, and presence of cytogenetic abnormalities, vitamin D insufficiency was an independent predictor of TTT. Thus, vitamin D levels in serum may represent an important prognostic marker for CLL.
Because CLL currently is incurable, it would be tempting to hope, as Pepper and Fegan speculate, that normalization of vitamin D might be beneficial for CLL patients(http://bloodjournal.
What about the role of vitamin D in preventing or improving outcomes in other types of cancer? Multiple, relevant mechanisms of action of vitamin D in preclinical studies on cancer abound (http://bloodjournal.
According to a recent meta-analysis by an Institute of Medicine (IOM) panel, however, the inconsistent research on vitamin D insufficiency and incidence and mortality of many types of solid tumors and non-Hodgkin's lymphoma - as well as that of cardiovascular disease, diabetes, and autoimmune diseases - does not prove a cause-effect relationship (www.nejm.org/doi/full/10.
Five to six years from now, data from ongoing clinical trials of moderate to high doses of vitamin D for chemoprevention of cancer will be available(Chustecka, 3/31/11, www.medscape.com; subscription required). Also, many clinical studies of vitamin D and its derivatives as therapeutics for a variety of cancers are in progress. In a best-case scenario, perhaps eventually we will be able to add prevention or treatment of some type of cancer as another rationale for vitamin D supplementation in certain patients. On the other hand, without compelling evidence of beneficial effect in other diseases, osteoporosis and related bone conditions remain the bona fide reasons for normalizing vitamin D.
Copyright 2011 A. Richard Adrouny, M.D., F.A.C.P.
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