The final results of the United Kingdom sentinel node training program: New Start

Abstract

629 Background: Formal introduction of new surgicaltechniques is rare, but the rate of technological advances in cancer surgery mandates that surgeons in current practice will need to learn new techniques in an enviroment less rigorous than residency programs. The rapid introduction of sentinel node biopsy in breast cancer is a classic exemplar of the problematic issues around quality assurance and patient safety in new technology. In the UK this technique was introduced in a unique formal program –The New Start training program –which utilised educational methods with a mandatory quality assurance system for each individual surgical team prior to routine introduction of the technique in practice. Methods: Every hospital had to submit the breast team to a formal program consisting of a theory training day followed by in house supervised training for the first 5 cases in the operating room in their instituition.Surgical teams performed 5 directly supervised procedures followed by 25 further audited cases with data being submitted centrally. All sentinel procedures were combination isotope/blue dye, (Nanocoll 99 Tm and a blue dye (Patent Blue V- laboratoires Guerbert Paris, France). In order to be approved each team had to achieve a localisation rate of at least 90% and a false negative rate of less than 10%. Results: The program has now trained 242 surgeons performing a total of 6341 audited sentinel node validation procedures. The localisation rate was 99% and the false negative rate was <8%. The median number of sentinel nodes was 2 and in 54% of the node positive patients, the sentinel node was the only positive node. Preoperative scintigraphy showed hotspots in 83% of patients. Blue dye reactions in this large dataset were lower than quoted in the literature, (<1% of patients), suggesting over-reporting in smaller trials. There was short learning curve for false negativity falling to <4% after 40 audited cases. Failure to find a sentinel node correlated strongly with a higher rate of histological node positivity. Conclusions: This major national training program with in house practical training has shown a high localisation rate and a shortened learning curve for false negative cases, and has demonstrated the value of a formal training program, which can form the template for the introduction of new surgical techniques. No significant financial relationships to disclose.