Abstract
BackgroundNeoadjuvant 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.MethodsMultidisciplinary 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.ResultsThirty-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.DiscussionThere 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.
Highlights
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
These findings will be corroborated in phase II of the Neoadjuvant Systemic Therapy in Breast Cancer (NeST) study which is a national collaborative prospective audit of NST utilisation and clinical outcomes
There is wide variation reported in the frequency with which neoadjuvant with adjuvant chemotherapy (NACT) is recommended in UK multidisciplinary team (MDT), we showed no difference in stated rates of use between teaching hospitals and District General Hospital (DGH), albeit in a relatively small number of hospitals using self-reported data
Summary
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. Breast cancer affects around 55,000 women per year in the United Kingdom, and over recent years breast cancer management has evolved, with increasing use of personalised approaches to therapy. This includes the use of neoadjuvant systemic therapy (NST), which may be used to reduce the extent of surgery, as well as to determine the sensitivity of a tumour to therapy in the in vivo setting. National guidance recommends offering primary systemic therapy to ER negative and HER2 positive invasive breast cancer, with international guidance recommending this approach for the treatment of stage 2 or 3 HER2 positive or triple negative disease [7, 8]
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