Responses were obtained from a total of 39 of 144 UK MDTs. Characteristics of participating centres’ service provision and MDT composition are summarised in Table 1.
Table 1: Demographics of participating breast units and multidisciplinary teams
Organisation
|
Number (%)
|
Teaching Hospital
|
23 (59)
|
DGH
|
15 (38)
|
Not stated
|
1 (3)
|
|
Service Provision
|
Symptomatic only
|
3 (8)
|
Screening/symptomatic
|
36 (92)
|
|
|
Actively recruiting to trials
|
|
100 (39)
|
|
Unit size
|
Median cases per year (range)
|
|
470 (220-1000)
|
|
MDT Composition
|
Median No. consultants (range)
|
Histopathologist
|
2 (1-8)
|
Radiologist
|
4 (1-9)
|
Oncologists
|
4 (1-10)
|
Clinical oncologist
Medical oncologist
|
2 (0-5)
2 (0-5)
|
Breast Surgeons
|
3 (0.5-10)
|
Oncoplastic Breast Surgeon
|
3 (0.5 -10)
|
Indications and Selection for Neoadjuvant Therapy
All MDTs in the study reported routinely offering NACT to their patients, with an estimated median of 10% (range 5-60%) cases being offered this modality. The median usage of NACT in teaching hospitals was 10% (range 5%-40%), as compared with 7.75% in DGHs (range 5-60%) (p=0.32, Mann-Whitney U test).
Twenty–six MDTs (66% of the total) routinely offered NET; a further 5% (n=2) offer NET only as a treatment option within a clinical trial. For teaching hospitals, 22% did not routinely offer NET, whereas for DGHs this figure was 27%. A median of 4% (range 0-25%) of patients were offered NET at these centres, with a median duration of treatment of 6 months (range: 3-9 months). At teaching hospitals, the median number of patients offered NET was 5% (range 0.2%-25%), and at DGHs the corresponding figures were 2.5% (range 0.5% - 12.5%) (p=0.41, Mann-Whitney U test).
Indications for recommending neoadjuvant therapy are summarised in Figure 1. The most common indication of the use of both NACT and NET was for the downstaging of disease, either to treat locally advanced disease or to downstage planned surgery
Neoadjuvant chemotherapy regimens most commonly reported being used are summarised in Figure 3, with the most commonly prescribed regimen being FEC-docetaxel/trastuzumab/pertuzumab for HER2-positive disease and FEC-docetaxel for HER2-negative disease. Preferred regimens were not stated in the responses from 6 MDTs (15%).
Neoadjuvant radiotherapy use in the UK is low, with 58% of respondents reporting that they do not use this approach, and a further 38% stating that they would only use it in the context of advanced or inoperable disease unresponsive to systemic therapies and one unit only using it in the context of a clinical trial (3%). One unit did not respond to this question.
Monitoring and management of treatment response
Monitoring of response information was provided for all MDTs. A marker clip is routinely sited in the breast by 97% of multidisciplinary teams when using NACT. In 79% of units this is prior to commencing treatment, with 21% varying the timing due to practicalities.
Preferred modalities for monitoring response to treatment are detailed in Figure 3 (a) and (b) for neoadjuvant chemotherapy and endocrine therapy respectively, with clinical assessment and/or ultrasound being utilised most often. Response is assessed at varying time points during treatment as follows:
- 45% mid-point and end of treatment
- 5% mid-point, end and other time point
- 3% mid-point and other time point
- 18% mid-point only
- 8% end of treatment only
- 18% other time point only
- 3% - varies with MDT consideration of cancer and patient characteristics
A quarter of MDTs (27%) stated they do not monitor response in patients planned to undergo mastectomy. Where response to NACT is monitored, results are routinely discussed in MDT meetings at 76% of centres with 22% of centres discussing selected patients only, and 2% (one centre) foregoing MDT discussion completely.
When using NET, 75% of MDTs site a marker clip; 86% of these centres deploy the clip prior to treatment, with 7% siting it during treatment and 7% varying the timing in response to practicalities. The median reported duration of NET was 6 months (range 3-9 months) before proceeding to surgery. All centres using NET monitor response clinically, with 95% also using radiological modalities (Figure 3). Patients on NET are routinely discussed in 60% of MDTs, selectively discussed in 30% of MDTs and not discussed in 10% of MDTs.
Post NST loco-regional treatment
When managing the breast post NST 74% of centres practise response-adapted surgery whereas 26% stated that they resect the original tumour footprint, regardless of the extent of clinical or radiological response to treatment. The majority of centres carry out post-NST sentinel lymph node biopsy (SLNB) in patients with clinically negative axillae at diagnosis (73% post-NACT and 84% post-NET). In patients with clinically positive axillary nodes at diagnosis 60% of centres stated that they would carry out axillary node clearance (ANC) regardless of response to NACT, and 69% (n=25) following NET. Thirteen percent of MDTs would re-assess the axilla following NACT and 25% following NET prior to making a surgical decision.
Post-NST, virtually all units stated that they would treate the conserved breast with adjuvant radiotherapy (97%). Post-mastectomy radiotherapy (PMRT) was largely driven by pre-treatment tumour size and nodal status, with 92% of MDTs stating that they give PMRT where pre-treatment tumour size was ≥50mm, and 87% giving supraclavicular fossa (SCF) radiotherapy based on a pre-treatment diagnosis of N2 disease.
Thirty six percent of units that perform SLNB prior to NST would proceed to an ANC post-treatment, without further assessing the axilla if sentinel nodes are positive. Patients found to have a positive axilla on post-NST SLNB are managed on an individualised basis at 31% (n=11) of centres following NACT and 54% (n=19) of centres following NET. Approximately half of MDTs would perform a completion ANC; 54% (n=19) following NACT, and 46% (n=16) for NET.
Histopathology
In 86% of MDTs, a reporting system is routinely used to describe the extent of pathological response to NACT. Figure 4 summarises the reporting systems used, with 2 centres not responding to this question (5%). Ki67 is routinely measured in post-NST specimens in only 11% of centres, with 8% reporting it in selected circumstances such as clinical trials, and 5% not responding. In contrast, only 46% of MDTs use a system to report response to NET, and 14 centres use a descriptive report only.