• Changing the standard of care for stage

    From ScienceDaily@1:317/3 to All on Friday, March 04, 2022 21:30:34
    Changing the standard of care for stage III melanoma surgery

    Date:
    March 4, 2022
    Source:
    University of Colorado Anschutz Medical Campus
    Summary:
    For years, surgery for patients with stage III melanoma -- melanoma
    that has spread to the lymph nodes -- involved removing those lymph
    nodes along with the primary tumor. Known as completion lymph node
    dissection (CLND), the surgery was meant to ensure that no cancer
    remained after surgery. More recently, however, cancer surgeons have
    discovered that CLND has the potential to cause more problems than
    it solves. In most cases, patients do better on immunotherapy alone
    than they do when their surgery involves removal of the lymph nodes,
    due to potential complications from lymph node surgery.



    FULL STORY ==========================================================================
    For years, surgery for patients with stage III melanoma -- melanoma that
    has spread to the lymph nodes -- involved removing those lymph nodes along
    with the primary tumor. Known as completion lymph node dissection (CLND),
    the surgery was meant to ensure that no cancer remained after surgery.


    ==========================================================================
    More recently, however, cancer surgeons have discovered that CLND has
    the potential to cause more problems than it solves. In most cases,
    patients do better on immunotherapy alone than they do when their surgery involves removal of the lymph nodes, due to potential complications from
    lymph node surgery.

    In a paper published in February in the Annals of Surgical Oncology,
    University of Colorado (CU) Cancer Center members Martin McCarter, MD,
    Camille Stewart, MD, Karl Lewis, MD, William Robinson, MD, Ana Gleisner,
    MD, PhD, and Rene Gonzalez, MD -- along with CU School of Medicine
    resident Robert Torphy, MD, PhD -- reviewed their patient data to
    determine if immunotherapy alone resulted in better outcomes than CLND.

    "In the few years prior to immunotherapy being available, some surgical
    trials were done asking if regional node dissection by itself improves
    overall survival for the patients," says McCarter, a professor of surgical oncology at the CU School of Medicine. "And the answer came back: no,
    it did not improve survival. That had been the standard forever, because
    we didn't have other effective therapies, but once the definitive trials
    were done, we learned that CLND wasn't helping, it wasn't improving
    survival. Subsequent trials demonstrated that immunotherapy can improve survival in metastatic melanoma." Better outcomes with immunotherapy
    For the study, Torphy, working with McCarter and the other researchers,
    looked at data on 90 patients who underwent sentinel lymph node biopsy
    (a procedure to determine if a skin melanoma has spread microscopically)
    only for stage III melanoma but did not undergo CLND. Of those patients,
    56 received immunotherapy and 34 did not. Those who received immunotherapy
    had better rates of distant metastasis-free survival, meaning their
    cancer was less likely to come back.



    ==========================================================================
    "As treatments for melanoma have evolved, the standard of care may
    be evolving as well," McCarter says. "This study took a look at the
    patients who had a sentinel lymph node biopsy, so we knew the patient
    had a positive melanoma metastasis to their regional node. Those
    folks historically used to go on and get the completion lymph node
    dissection, but recently, people started to forego doing that lymph
    node dissection, which did not improve survival, and instead moved
    directly to immunotherapy, which did improve survival in other clinical
    trials. We proved that this is acceptable, that we're not causing more
    harm to patients by doing it, and that those who do go on to get the immunotherapy seem to benefit from it." The de-escalation movement
    Forgoing CLND is part of a recent movement in cancer treatment known
    as de- escalation (or de-implementation) -- giving patients only the
    surgery absolutely necessary to treat their immediate disease. It's
    especially important when it comes to lymph node surgery, McCarter says,
    as on top of the risks inherent to all surgeries, CLND has a 20% to 30%
    risk of permanent lymphedema, potentially harmful tissue swelling caused
    by an accumulation of protein-rich fluid that's usually drained through
    the body's lymphatic system.

    "If you could avoid that complication and not compromise a patient's
    survival, that would be beneficial," McCarter says. "That's what we
    guessed was happening outside of definitive clinical trial evidence,
    and that's what we were able to show. We know that we often overtreat
    patients, and this fits in that paradigm of finding ways to de-escalate unnecessary therapies, which has been done in breast cancer and other
    cancers as well." Changing course The CU researchers hope the study
    begins to move the needle for cancer surgeons for whom CLND is still
    routine, despite the earlier studies showing that the additional surgery
    was not improving survival.

    "Previous clinical trials with the use of adjuvant immunotherapy
    for melanoma had required a CLND," McCarter says. "This study used
    real-world data from our stage III melanoma patients who were treated
    with immunotherapy without having a prior CLND.

    "It takes years to change people's practice patterns. I still have conversations with community surgeons who treat melanoma, asking
    me, 'Should I be doing these regional node dissections?' even
    though this data has been out for five to 10 years now," McCarter
    continues. "They're afraid to give up what they used to do, and they're
    afraid that they are doing a disservice to the patients or not giving
    them the best chance, when in reality, our understanding of cancer
    biology has evolved. We now have effective immunotherapy, which is
    overcoming some of the limitations of surgery while improving outcomes." ========================================================================== Story Source: Materials provided by University_of_Colorado_Anschutz_Medical_Campus. Original written by Greg Glasgow. Note: Content may be edited for style and length.


    ========================================================================== Journal Reference:
    1. Robert J. Torphy, Chloe Friedman, Felix Ho, Laura D. Leonard, Daniel
    Thieu, Karl D. Lewis, Theresa M. Medina, William A. Robinson,
    Rene C.

    Gonzalez, Camille L. Stewart, Nicole Kounalakis, Martin D. McCarter,
    Ana Gleisner. Adjuvant Therapy for Stage III Melanoma Without
    Immediate Completion Lymph Node Dissection. Annals of Surgical
    Oncology, 2021; 29 (2): 806 DOI: 10.1245/s10434-021-10775-8 ==========================================================================

    Link to news story: https://www.sciencedaily.com/releases/2022/03/220304124017.htm

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