Multidisciplinary Expert Consensus Research Articles

Clinical Recommendations for Managing Genitourinary Adverse Effects in Patients Treated with SGLT-2 Inhibitors: A Multidisciplinary Expert Consensus.

Background: SGLT-2 inhibitors (SGLT-2is) are considered to be a first-line treatment for common conditions like type 2 diabetes, chronic kidney disease, and heart failure due to their proven ability to reduce cardiovascular and renal morbidity and mortality. Despite these benefits, SGLT-2is are associated with certain adverse effects (AEs), particularly genitourinary (GU) events, which can lead to treatment discontinuation in some patients. Preventing these AEs is essential for maintaining the cardiorenal benefits of SGLT-2is. Methods: A multidisciplinary panel of experts from various medical specialties reviewed the best available evidence on GU AEs associated with SGLT-2i therapy. The panel focused on the prevention and management of genital mycotic infections, urinary tract infections, and lower urinary tract symptoms in both the general population and high-risk groups, such as renal and cardiac transplant recipients. Results: The panel found that permanent discontinuation of SGLT-2is results in a rapid loss of cardiorenal benefits. Preventive strategies, including identifying high-risk patients before initiating therapy, are critical for minimizing GU AEs. Clinical trials show that most GU infections linked to SGLT-2i therapy are mild to moderate in severity and typically respond to standard antimicrobial treatment, without the need for discontinuation. Conclusions: Routine discontinuation of SGLT-2is due to GU AEs is not recommended. Therapy should be resumed as soon as possible, unless severe or persistent conditions contraindicate their use, in order to preserve the significant benefits of SGLT-2is in reducing cardiovascular and renal events.

The role of dietary modification in the prevention and management of metabolic dysfunction-associated fatty liver disease: An international multidisciplinary expert consensus

Metabolic dysfunction-associated fatty liver disease (MAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD), has become the leading cause of chronic liver disease worldwide. Optimal dietary intervention strategies for MAFLD are not standardized. This study aimed to achieve consensus on prevention of MAFLD through dietary modification. A multidisciplinary panel of 55 international experts, including specialists in hepatology, gastroenterology, dietetics, endocrinology and other medical specialties from six continents collaborated in a Delphi-based consensus development process. The consensus statements covered aspects ranging from epidemiology to mechanisms, management, and dietary recommendations for MAFLD. The recommended dietary strategies emphasize adherence to a balanced diet with controlled energy intake and personalized nutritional interventions, such as calorie restriction, high-protein, or low-carbohydrate diets. Specific dietary advice encouraged increasing the consumption of whole grains, plant-based proteins, fish, seafood, low-fat or fat-free dairy products, liquid plant oils, and deeply colored fruits and vegetables. Concurrently, it advised reducing the intake of red and processed meats, saturated and trans fats, ultra-processed foods, added sugars, and alcohol. Additionally, maintaining the Mediterranean or DASH diet, minimizing sedentary behavior, and engaging in regular physical activity are recommended. These consensus statements lay the foundation for customized dietary guidelines and proposing avenues for further research on nutrition and MAFLD.

An optimal trauma-informed pathway for PTSD, complex PTSD and other mental health and psychosocial impacts of trauma in prisons: an expert consensus statement

ABSTRACT People in prisons have high levels of trauma exposure throughout their lives. Presentations are often complex, with a high prevalence of PTSD and CPTSD and other mental health comorbidities. Prisons themselves can be stressful and traumatising environments. There are challenges in the delivery of effective treatments for PTSD and CPTSD. There is a need for the development of effective clinical pathways for these conditions that are embedded within trauma-informed organisational approaches. Responding to this need, this report is the result of a multidisciplinary expert consensus meeting and review of the research literature on PTSD, CPTSD, associated comorbidities and optimal approaches to trauma-informed practice. The group consisted of 24 expert representatives from psychology, psychiatry, healthcare, academia, social care and Welsh Government. The meeting commenced with presentations on various aspects of the clinical pathway for PTSD and complex PTSD in prisons, and of applications of trauma-informed practice within prisons. Small sub-groups then provided practical recommendations and solutions relevant to their assigned topic. Findings were presented to all meeting attendees for another round of discussion and debate, until consensus was reached. The resulting recommendations provide guidance to improve identification, treatment and support for people living in prison who have experienced trauma.

Controversies in prostate cancer management: Consensus recommendations from experts in northern Spain

In recent years, various aspects of prostate cancer (PC) management have undergone significant changes, including the implementation of therapeutic strategies such as the use of new hormonal agents like abiraterone, apalutamide, enzalutamide or darolutamide and the incorporation of next generation imaging techniques (NGI). However, the evidence regarding the role of NGI and the therapeutic decision-making based on their findings is not solid. Following the methodology of the Advanced Prostate Cancer Consensus Conference (APCCC), a multidisciplinary expert consensus was developed to address controversial questions concerning the use of NGI and clinical management in four priority scenarios: localized PC, PC after radical prostatectomy, PC after radiotherapy with curative intent, and metastatic hormone-sensitive PC. This consensus represents the opinions of medical oncology, radiation oncology and urology physicians and provides useful recommendations for clinical practice.

Evidence-based expert consensus on clinical management of safety of Bruton's tyrosine kinase inhibitors (2024).

Bruton's tyrosine kinase inhibitors (BTKis) have revolutionized the treatment of B-cell lymphomas. However, safety issues related to the use of BTKis may hinder treatment continuity and further affect clinical efficacy. A comprehensive and systematic expert consensus from a pharmacological perspective is lacking for safety issues associated with BTKi treatment. A multidisciplinary consensus working group was established, comprising 35 members from the fields of hematology, cardiovascular disease, cardio-oncology, clinical pharmacy, and evidence-based medicine. This evidence-based expert consensus was formulated using an evidence-based approach and the Delphi method. The Joanna Briggs Institute Critical Appraisal (JBI) tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach were used to rate the quality of evidence and grade the strength of recommendations, respectively. This consensus provides practical recommendations for BTKis medication based on nine aspects within three domains, including the management of common adverse drug events such as bleeding, cardiovascular events, and hematological toxicity, as well as the management of drug-drug interactions and guidance for special populations. This multidisciplinary expert consensus could contribute to promoting a multi-dimensional, comprehensive and standardized management of BTKis.

Recommendations to Improve Management of Incidental Pulmonary Nodules in Canada: Expert Panel Consensus.

Introduction: Incidental pulmonary nodules (IPN) are common radiologic findings, yet management of IPNs is inconsistent across Canada. This study aims to improve IPN management based on multidisciplinary expert consensus and provides recommendations to overcome patient and system-level barriers. Methods: A modified Delphi consensus technique was conducted. Multidisciplinary experts with extensive experience in lung nodule management in Canada were recruited to participate in the panel. A survey was administered in 3 rounds, using a 5-point Likert scale to determine the level of agreement (1 = extremely agree, 5 = extremely disagree). Results: Eleven experts agreed to participate in the panel; 10 completed all 3 rounds. Consensus was achieved for 183/217 (84.3%) statements. Panellists agreed that radiology reports should include a standardized summary of findings and follow-up recommendations for all nodule sizes (ie, <6, 6-8, and >8 mm). There was strong consensus regarding the importance of an automated system for patient follow-up and that leadership support for organizational change at the administrative level is of utmost importance in improving IPN management. There was no consensus on the need for standardized national referral pathways, development of new guidelines, or establishing a uniform picture archiving and communication system. Conclusion: Canadian IPN experts agree that improved IPN management should include standardized radiology reporting of IPNs, standardized and automated follow-up of patients with IPNs, guideline adherence and implementation, and leadership support for organizational change. Future research should focus on the implementation and long-term effectiveness of these recommendations in clinical practice.

Controversias en el abordaje del cáncer de próstata: consenso de recomendaciones de expertos del norte de España

In recent years, various aspects of prostate cancer (PC) management have undergone significant changes, including the implementation of therapeutic strategies such as the use of new hormonal agents like abiraterone, apalutamide, enzalutamide or darolutamide and the incorporation of next generation imaging techniques. However, the evidence regarding the role of next generation imaging techniques and the therapeutic decision-making based on their findings is not solid. Following the methodology of the Advanced Prostate Cancer Consensus Conference, a multidisciplinary expert consensus was developed to address controversial questions concerning the use of next generation imaging techniques and clinical management in 4 priority scenarios: localized PC, PC after radical prostatectomy, PC after radiotherapy with curative intent, and metastatic hormone-sensitive PC. This consensus represents the opinions of medical oncology, radiation oncology and urology physicians, and provides useful recommendations for clinical practice.

Methodological proposals for developing trustworthy recommendations of integrative Chinese-Western medicine

BackgroundTo refine the methods of developing clinical practice guidelines (CPGs) for integrative Chinese-Western medicine (ICWM), promoting the formation of trustworthy, implementable recommendations that integrate the strengths of Chinese and Western medicine. MethodsUsing a nominal group technique (NGT) approach, a multidisciplinary expert panel was established. The panel identified key methodological issues in ICWM-CPG development through literature review and iterative discussions, and formulated methodological proposals to address these issues. The final set of proposals was achieved through consensus among the panel members. ResultsThe collaborative effort resulted in the identification of five pivotal methodological issues and the subsequent establishment of 22 specific recommendations. These encompass strict adherence to renowned standards, such as those proposed by the Institute of Medicine (IOM) and Guidelines International Network (G-I-N), the employment of methodologies like the GRADE approach and RIGHT statement, the strategic constitution of a balanced development group, the adept identification of ICWM-focused clinical inquiries, the nuanced integration of diverse evidence sources, and the detailed crafting of transparent, implementable recommendations. ConclusionsThis study concentrates on the most crucial and prevalent methodological issues in ICWM-CPG development, proposing a series of recommendations. These suggestions result from a multidisciplinary expert consensus, aiming to provide methodological guidance for ICWM-CPG developers, building upon the current foundational methodologies.

Multidisciplinary expert consensus on the clinical rational application of different formulations of amphotericin B (2024 edition)

Amphotericin B (AmB) is a broad-spectrum and potent polyene antifungal drug for the treatment of invasive fungal diseases (IFDs). Currently, amphotericin B deoxycholate (AmB-D) and three AmB lipid formulations, namely liposomal amphotericin B (L-AmB), amphotericin B colloidal dispersion (ABCD), and amphotericin B lipid complex (ABLC) are available for clinical use. In view of clinical concerns and misperceptions in the selection of different formulations of AmB, the present consensus summarized their pharmaceutical characteristics, antifungal mechanism, pharmacokinetics/phamacodynamics, drug interactions, indications, dosage, local administration, and adverse reactions based on the latest clinical research evidence, guidelines, and clinical experience. This consensus also recommends formulation selection and dosage adjustment for the treatment of target IFDs and in special populations, thereby providing expert consensus for clinical decision-making and standardized application of AmB.

Magnetic resonance imaging scoring system of the lower limbs in adult patients with suspected idiopathic inflammatory myopathy

PurposeWe aim to propose a visual quantitative score for muscle edema in lower limb MRI to contribute to the diagnosis of idiopathic inflammatory myopathy (IIM).Material and methodsWe retrospectively evaluated 85 consecutive patients (mean age 57.4 ± 13.9 years; 56.5% female) with suspected IIM (muscle weakness and/or persistent hyper-CPK-emia with/without myalgia) who underwent MRI of lower limbs using T2-weighted fast recovery-fast spin echo images and fat-sat T2 echo planar images. Muscle inflammation was evaluated bilaterally in 11 muscles of the thigh and eight muscles of the leg. Edema in each muscle was graded according to a four-point Likert-type scale adding up to 114 points ([11 + 8)] × 3 × 2). Diagnostic accuracy of the total edema score was explored by assessing sensitivity and specificity using the area under the ROC curve. Final diagnoses were made by a multidisciplinary Expert Consensus Panel applying the Bohan and Peter diagnostic criteria whenever possible.ResultsOf the 85 included patients, 34 (40%) received a final diagnosis of IIM (IIM group) while 51 (60%) received an alternative diagnosis (non-IIM group). A cutoff score ≥ 18 was able to correctly classify patients having an IIM with an area under the curve of 0.85, specificity of 96%, and sensitivity of 52.9%.ConclusionOur study demonstrates that a quantitative MRI score for muscle edema in the lower limbs (thighs and legs) aids in distinguishing IIM from conditions that mimic it.

Incidental pulmonary nodule management in Canada: exploring current state through a narrative literature review and expert interviews.

Incidental pulmonary nodules (IPNs) are common and increasingly detected with the overall rise of radiologic imaging. Effective IPN management is necessary to ensure lung cancer is not missed. This study aims to describe the current landscape of IPN management in Canada, understand barriers to optimal IPN management, and identify opportunities for improvement. We performed a narrative literature review by searching biomedical electronic databases for relevant articles published between January 1, 2010, and November 22, 2023. To validate and complement the identified literature, we conducted structured interviews with multidisciplinary experts involved in the pathway of patients with IPNs across Canada. Interviews between December 2021 and May 2022 were audiovisual recorded, transcribed, and thematically analyzed. A total of 1,299 records were identified, of which 37 studies were included for analysis. Most studies were conducted in Canada and the United States and highlighted variability in radiology reporting of IPNs and patient management, and limited adherence to recommended follow-up imaging. Twenty experts were interviewed, including radiologists, respirologists, thoracic surgeons, primary care physicians, medical oncologists, and an epidemiologist. Three themes emerged from the interviews, supported by the literature, including: variability in radiology reporting of IPNs, suboptimal communication, and variability in guideline adherence and patient management. Despite general awareness of guidelines, there is inconsistency and lack of standardization in the management of patients with IPNs in Canada. Multidisciplinary expert consensus is recommended to help overcome the communication and operational barriers to a safe and cost-effective approach to this common clinical issue.

Best Practices for the Evaluation and Management of Low Back Pain in Primary Care: A Multidisciplinary Expert Consensus

Abstract Purpose: International guidelines for the management of patients with low back pain (LBP) are available, but there are no India-specific guidelines for the diagnosis and management of LBP in primary care. This article aims to provide clinical insights for the diagnosis and treatment of LBP for primary care practitioners in India. Methods: A 3-step modified Delphi method was used to get insights and opinions from a panel of 9 multidisciplinary specialist (neurology, orthopedics, and pain management). In rounds 1 and 2, 203 and 60 statements, respectively, were circulated to the expert panel and they were asked to respond with an “agree” or “disagree” to each statement and provide comments. At least 80% of the experts had to agree for a statement to reach a concordance. More than 80% concordance was reached for 175 and 32 statements in rounds 1 and 2, respectively. Round 3 was a direct interaction with the experts. Results: There was good agreement among the expert panelist in round 3 for the consensus-derived statements from the earlier two rounds of the survey. The panel agreed that diagnostic triage is important to exclude specific spinal pathology, routine imaging is not recommended unless suspecting serious pathology, specialist referral is needed for serious pathologies/no improvement in pain with treatment, and management is to be individualized depending on etiology and patient factors. Conclusions: Primary care physicians are the first point of contact for patients with back pain. These consensus recommendations will assist primary care physicians in India to choose an appropriate course of action for managing patients with LBP.

Multidisciplinary Expert Consensus Statements and Recommendations for Use of Hypochlorous Acid as a Solution for Negative Pressure Wound Therapy With Instillation

Multidisciplinary Expert Consensus Statements and Recommendations for Use of Hypochlorous Acid as a Solution for Negative Pressure Wound Therapy With Instillation

OGC P46 A consensus opinion on the best prehabilitation strategies for Upper GI cancer patients

Abstract Background Upper GI (UGI) cancer patients face substantial physical and functional challenges which can compromise postoperative recovery. Prehabilitation, a proactive multidisciplinary intervention, offers a promising approach to optimize patient outcomes. This Delphi exercise aims to gather a consensus on the effectiveness of various prehabilitation strategies and interventions in improving functional capacity, reducing treatment-related complications, and enhancing quality of life among UGI cancer patients. Methods We performed a Delphi exercise in the form of an online survey emailed to a group of surgeons, anaesthetists, specialist nurses and allied healthcare professionals involved in the perioperative care of UGI cancer patients. A 2-staged iterative process was used to gather consensus on clinical practice and expert opinion. In the second round the survey was refined to evaluate specific strategies of prehabilitation more closely. Results In the first round, 14 statements were evaluated in addition to basic demographic data, information about the unit and clinician experience. 161 responses were collected from surgeons, anaesthetists, specialist nurses and allied healthcare professionals. Consensus was reached on formal assessment of patient fitness pre-operatively. However no consensus was achieved in the best method for doing so. In the second round we evaluated 22 statements after refining the questions to specifically target prehabilitation exercises and formal fitness assessments available for the perioperative care of UGI cancer patients. Conclusions Prehabilitation interventions hold significant potential in optimizing outcomes and improving the quality of life for UGI cancer patients undergoing major surgery. This Delphi exercise provides multidisciplinary expert consensus statements which can help guide clinicians in day-to-day practice as well as provide a basis for future guidelines and recommendations.

Perioperative patient safety recommendations: best practices derived from a systematic review and a multidisciplinary expert consensus

Abstract Surgery care has one of the highest pooled prevalence of preventable patient harm. Many clinical practice guidelines have been developed around the world to overcome this safety and public health concern. Moreover, clinical practice guideline (CPG) recommendations may efficiently provide a sound source of evidence-based practices for quality indicator development. However, the question is which healthcare processes should be measured. The “Improving quality and patient SAFEty in surgical care through STandardisation and harmonisation of perioperative care in Europe” (SAFEST) project aimed to reach a Europe-wide consensus on perioperative patient safety recommendations for adults that will be further transformed in quality measures and guide implementation activities. To achieve such a goal, a systematic review of CPGs was performed, identifying more than 250 CPGs and more than 2600 recommendations; eventually selected and synthesized into 99 recommendations. Then, we recruited an expert panel including organisations from the European Region, and focusing on a balanced representation of geographical location, clinical and non-clinical expertise, and gender. A two-round online Delphi was conducted, and a Consensus Conference was held in Brussels. During the entire process, some recommendations were reworded, separated, merged, added or removed. Additionally, feasibility and equity concerns emerged and were further explored in-person during the conference. Finally, a list of 101 perioperative patient safety recommendations was agreed. These evidence-based practices incorporate clinical and managerial experts’ considerations as well as patient representatives’ reflections. In conclusion, this presentation will explore the relationship between recommendations and quality of care indicators. We will discuss the usefulness of SAFEST evidence-based recommendations, and their pros and cons as process and structure quality measures.

One step at a time. Shaping consensus on research priorities and terminology in telehealth in musculoskeletal pain: an international modified e-Delphi study

BackgroundTelehealth has emerged as an alternative model for treatment delivery and has become an important component of health service delivery. However, there is inconsistency in the use of terminologies and a lack of research priorities in telehealth in musculoskeletal pain. The purpose of this international, multidisciplinary expert panel assembled in a modified three-round e-Delphi survey is to achieve a consensus on research priorities and for the standard terminology for musculoskeletal pain telehealth practice.MethodsIn this international modified e-Delphi survey, we invited an expert panel consisting of researchers, clinicians, consumer representatives, industry partners, healthcare managers, and policymakers to participate in a three-round e-Delphi. Expert panels were identified through the Expertscape website, PubMed database, social media, and a snowball approach. In Round 1, potential research priorities and terminologies were presented to panel members. Panel members rated the agreement of each research priority on a 5-point Likert scale and an 11-point numerical scale, and each terminology on a 5-point Likert scale for the "telehealth in musculoskeletal pain " field over rounds. At least 80% of the panel members were required to agree to be deemed a consensus. We analyzed the data descriptively and assessed the stability of the results using the Wilcoxon matched-pairs signed rank test.ResultsWe performed an international e-Delphi survey from February to August 2022. Of 694 invited people, 160 panel members participated in the first round, 133 in the second round (83% retention), and 134 in the third round (84% retention). Most of the panel members were researchers 76 (47%), clinicians 57 (36%), and consumer representatives 9 (6%) of both genders especially from Brazil 31 (19%), India 22 (14%), and Australia 19 (12%) in the first round. The panel identified fourteen telehealth research priorities spanned topics including the development of strategies using information and communication technology, telehealth implementation services, the effectiveness and cost-effectiveness of telehealth interventions, equity of telehealth interventions, qualitative research and eHealth literacy in musculoskeletal pain conditions from an initial list of 20 research priorities. The consensus was reached for "digital health" and "telehealth" as standard terminologies from an initial list of 37 terminologies.ConclusionAn international, multidisciplinary expert consensus recommends that future research should consider the 14 research priorities for telehealth musculoskeletal pain reached. Additionally, the terms digital health and telehealth as the most appropriate terminologies to be used in musculoskeletal telehealth research.RegisterOpen Science Framework (https://osf.io/tqmz2/).

Cancer-Related Pain Management in Suitable Intrathecal Therapy Candidates: A Spanish Multidisciplinary Expert Consensus.

A consensus is needed among healthcare professionals involved in easing oncological pain in patients who are suitable candidates for intrathecal therapy. A Delphi consultation was conducted, guided by a multidisciplinary scientific committee. The 18-item study questionnaire was designed based on a literature review together with a discussion group. The first-round questionnaire assessed experts' opinion of the current general practice, as well as their recommendation and treatment feasibility in the near future (2-3-year period) using a 9-point Likert scale. Items for which consensus was not achieved were included in a second round. Consensus was defined as ≥75% agreement (1-3 or 7-9). A total of 67 panelists (response rate: 63.2%) and 62 (92.5%) answered the first and second Delphi rounds, respectively. The participants were healthcare professionals from multiple medical disciplines who had an average of 17.6 (7.8) years of professional experience. A consensus was achieved on the recommendations (100%). The actions considered feasible to implement in the short term included effective multidisciplinary coordination, improvement in communication among the parties, and an assessment of patient satisfaction. Efforts should focus on overcoming the barriers identified, eventually leading to the provision of more comprehensive care and consideration of the patient's perspective.

Smart e-Skin Cancer Care in Europe During and after the Covid-19 Pandemic: a Multidisciplinary Expert Consensus.

Melanoma is the deadliest of all the skin cancers and its incidence is increasing every year in Europe. Patients with melanoma often present late to the specialist and treatment is delayed for many reasons (delay in patient consultation, misdiagnosis by general practitioners, and/or limited access to dermatologists). Beyond this, there are significant inequalities in skin cancer between population groups within the same country and between countries across Europe. The emergence of the COVID-19 pandemic only aggravated these health deficiencies. The aim was to create an expert opinion about the challenges in skin cancer management in Europe during the post COVID-19 acute pandemic and to identify and discuss the implementation of new technologies (including e-health and artificial intelligence defined as "Smart Skin Cancer Care") to overcome them. For this purpose, an ad-hoc questionnaire with items addressing topics of skin cancer care was developed, answered independently and discussed by a multidisciplinary European panel of experts comprising dermatologists, dermato-oncologists, patient advocacy representatives, digital health technology experts, and health technology assessment experts. After all panel of experts discussions, a multidisciplinary expert opinion was created. As a conclusion, the access to dermatologists is difficult and will be aggravated in the near future. This fact, together with important differences in Skin Cancer Care in Europe, suggest the need of a new approach to skin health, prevention and disease management paradigm (focused on integration of new technologies) to minimize the impact of skin cancer and to ensure optimal quality and equity.

Multidisciplinary expert consensus on the rational use of tetracyclines commonly used in clinical practice

In recent years, the emergence of newly detected pathogens and the increase of drug resistant bacterial bring serious challenges for the diagnosis and treatment of infectious diseases. Tetracycline drugs are widely used in clinical practice, and the varieties of these drugs are constantly being updated. However, there is still a lack of guidance documents for the rational clinical application of tetracycline drugs in China. Meanwhile, some healthcare workers have doubts about their pharmaceutical characteristics, timing and methods of clinical application. In order to further standardize the clinical application of tetracycline drugs and provide professional evidence-based medicine suggestions for medical personnel in medical institutions, under the leadership of Hospital Infection Control Branch of Chinese Preventive Medicine Association and Clinical Pharmacology Branch of Chinese Pharmacological Society, experts from areas of infection, respiratory medicine, critical care medicine, emergency, infection control, pharmacy and other disciplines organized a consensus meeting and formulated multidisciplinary expert consensus on the rational use of tetracyclines commonly used in clinical practice. This expert consensus is based on the pharmaceutical characteristics of tetracyclines commonly used in China, the mechanism of action and drug resistance status of tetracyclines, combined with the infection site, pathogen characteristics and bacterial drug resistance. This expert consensus also pays attention to special populations and off-label drug use, and integrates domestic and foreign recommendations and the latest evidence-based medicine evidence, and 17 expert consensus opinions for clinical physicians, pharmacists, and other professionals in medical institutions to refer to were formed. In view of the particularity and complexity of infectious diseases and the individual differences of patients, in order to benefit patients, individualized anti-infection strategies should be implemented.

The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus.

Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy (±targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.