I Whitehead1, G W Irwin2, F Bannon3, C E Coles4, E Copson5, R I Cutress5, R V Dave6, M D Gardiner7, M Grayson8, C Holcombe9, S Irshad10,11, C O'Brien12,13, R L O'Connell14, C Palmieri15,16, A M Shaaban17, N Sharma18, J K Singh17, S Potter19,20, S A McIntosh21. 1. Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK. 2. Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK. 3. Centre for Public Health, Queen's University Belfast, Institute of Clinical Science, Block A, Royal Victoria Hospital, Belfast, BT12 6BA, UK. 4. University of Cambridge, Cambridge, UK. 5. Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK. 6. The Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK. 7. Department of Plastic Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, SL2 4HL, UK. 8. NI Cancer Research Consumer Forum, c/o NI Cancer Trials Network, East Podium, C-Floor, Belfast City Hospital, Belfast, BT9 7AB, UK. 9. Liverpool University Hospitals Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK. 10. Guy's Cancer Centre, Guy's & St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK. 11. School of Cancer & Pharmaceutical Sciences, King's College London, London, SE1 9RT, UK. 12. The Christie Hospital NHS Foundation Trust, Wilmslow Road, Manchester, M20 2BX, UK. 13. School of Medical Sciences Faculty of Biology, Medicine and Health University of Manchester, Manchester, M13 9PL, UK. 14. Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK. 15. University of Liverpool, Institute of Systems, Molecular and Integrative Biology, Department of Molecular and Clinical Cancer Medicine, Liverpool, UK. 16. The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK. 17. Queen Elizabeth Hospital Birmingham and University of Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK. 18. Breast Unit, Level 1 Chancellor wing, St James Hospital, Beckett Street, Leeds, LS97TF, UK. 19. Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK. 20. Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK. 21. Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK. s.mcintosh@qub.ac.uk.
Abstract
BACKGROUND: Neoadjuvant systemic therapy (NST) is increasingly used in the treatment of breast cancer, yet it is clear that there is significant geographical variation in its use in the UK. This study aimed to examine stated practice across UK breast units, in terms of indications for use, radiological monitoring, pathological reporting of treatment response, and post-treatment surgical management. METHODS: Multidisciplinary teams (MDTs) from all UK breast units were invited to participate in the NeST study. A detailed questionnaire assessing current stated practice was distributed to all participating units in December 2017 and data collated securely usingREDCap. Descriptive statistics were calculated for each questionnaire item. RESULTS: Thirty-nine MDTs from a diverse range of hospitals responded. All MDTs routinely offered neoadjuvant chemotherapy (NACT) to a median of 10% (range 5-60%) of patients. Neoadjuvant endocrine therapy (NET) was offered to a median of 4% (range 0-25%) of patients by 66% of MDTs. The principal indication given for use of neoadjuvant therapy was for surgical downstaging. There was no consensus on methods of radiological monitoring of response, and a wide variety of pathological reporting systems were used to assess tumour response. Twenty-five percent of centres reported resecting the original tumour footprint, irrespective of clinical/radiological response. Radiologically negative axillae at diagnosis routinely had post-NACT or post-NET sentinel lymph node biopsy (SLNB) in 73.0 and 84% of centres respectively, whereas 16% performed SLNB pre-NACT. Positive axillae at diagnosis would receive axillary node clearance at 60% of centres, regardless of response to NACT. DISCUSSION: There is wide variation in the stated use of neoadjuvant systemic therapy across the UK, with general low usage of NET. Surgical downstaging remains the most common indication of the use of NAC, although not all centres leverage the benefits of NAC for de-escalating surgery to the breast and/or axilla. There is a need for agreed multidisciplinary guidance for optimising selection and management of patients for NST. These findings will be corroborated in phase II of the NeST study which is a national collaborative prospective audit of NST utilisation and clinical outcomes.
BACKGROUND: Neoadjuvant systemic therapy (NST) is increasingly used in the treatment of breast cancer, yet it is clear that there is significant geographical variation in its use in the UK. This study aimed to examine stated practice across UK breast units, in terms of indications for use, radiological monitoring, pathological reporting of treatment response, and post-treatment surgical management. METHODS: Multidisciplinary teams (MDTs) from all UK breast units were invited to participate in the NeST study. A detailed questionnaire assessing current stated practice was distributed to all participating units in December 2017 and data collated securely usingREDCap. Descriptive statistics were calculated for each questionnaire item. RESULTS: Thirty-nine MDTs from a diverse range of hospitals responded. All MDTs routinely offered neoadjuvant chemotherapy (NACT) to a median of 10% (range 5-60%) of patients. Neoadjuvant endocrine therapy (NET) was offered to a median of 4% (range 0-25%) of patients by 66% of MDTs. The principal indication given for use of neoadjuvant therapy was for surgical downstaging. There was no consensus on methods of radiological monitoring of response, and a wide variety of pathological reporting systems were used to assess tumour response. Twenty-five percent of centres reported resecting the original tumour footprint, irrespective of clinical/radiological response. Radiologically negative axillae at diagnosis routinely had post-NACT or post-NET sentinel lymph node biopsy (SLNB) in 73.0 and 84% of centres respectively, whereas 16% performed SLNB pre-NACT. Positive axillae at diagnosis would receive axillary node clearance at 60% of centres, regardless of response to NACT. DISCUSSION: There is wide variation in the stated use of neoadjuvant systemic therapy across the UK, with general low usage of NET. Surgical downstaging remains the most common indication of the use of NAC, although not all centres leverage the benefits of NAC for de-escalating surgery to the breast and/or axilla. There is a need for agreed multidisciplinary guidance for optimising selection and management of patients for NST. These findings will be corroborated in phase II of the NeST study which is a national collaborative prospective audit of NST utilisation and clinical outcomes.
Entities:
Keywords:
Breast cancer; Chemotherapy; Endocrine therapy; Neoadjuvant treatment; Surgery
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