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Breast Ca Surgeons Slow to Adopt 'Major' Practice Changes

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Medpage Today

Breast Ca Surgeons Slow to Adopt ‘Major’ Practice Changes

High-volume surgeons had lower propensity for unneeded procedure

MedpageToday

  • by Deputy Managing Editor, MedPage Today

Despite guidelines from as far back as 2012 stating that axillary lymph node dissection (ALND) is no longer needed in certain early-stage breast cancer patients, most surgeons said they would still likely perform the more involved procedure, a survey study found.

For patients with clinically node-negative breast cancer and ≤2 sentinel nodes with macrometastasis, 49% of surveyed surgeons said they would “definitely or probably” recommend ALND in a patient with macrometastasis in a single node, reported Monica Morrow, MD, of the Department of Surgery at Memorial Sloan Kettering Cancer Center in New York City, and colleagues.

“Although avoidance of axillary dissection has been shown to be safe in high-quality studies, half of surgeons still do it routinely,” Morrow told MedPage Today. “This practice is most common among surgeons not doing a lot of breast cancer, indicating a quality gap.”

And 62.6% of surgeons said they would also opt for ALND if two sentinel nodes had macrometastasis.

“Z0011 clearly demonstrated axillary dissection was not necessary for those two scenarios,” said Morrow.

First presented at a meeting in 2010, the American College of Surgeons Oncology Group Z0011 trial changed practice, revealing that ALND was no better than sentinel node biopsy (SNB) alone in terms of locoregional recurrence or survival among clinically node-negative breast cancer patients with metastases in one or two sentinel nodes. Following breast-conservation surgery, patients also received whole-breast radiation therapy (RT). Guidelines from both the National Comprehensive Cancer Network and the American Society of Clinical Oncology have both reflected the results of the trial since shortly after its publication in 2011.

“This issue needs to be addressed through targeted, clear education,” said Morrow. “These findings were considered very controversial by some when first published, but are now confirmed in other studies and with longer follow-up, and this needs to be made clear to non-specialist surgeons.”

The current study in JAMA Oncology invited 488 surgeons to participate in a survey of five clinical scenarios meant to tease out their acceptance of evidence-based guidelines for use of ALND.

In all 376 responded, 359 of whom filled out the clinical scenario portions of the surveys completely. Mean participant age was 53.7, and most were men (73.7%). A total of 37.8% of respondents were from low-volume centers, treating 20 breast cancer cases or fewer in the year prior to the survey. The rest were high-volume surgeons, with 29.8% seeing 21 to 50 cases and 28.7% seeing more than 50 in the prior year. Surgeons were found by searching data from the Surveillance, Epidemiology, and End Results (SEER) sites in Georgia and Los Angeles.

In multivariable analysis, surgeons were found to be have a significantly lower propensity to use ALND if they had a higher volume of breast cancer cases in the previous year:

  • 21-50 cases: -0.19, 95% CI -0.39 to 0.02
  • >51 cases: -0.48, 95% CI -0.71 to -0.24

“The finding that surgeons have been slow to adopt major practice changes is not new,” wrote Sara H. Javid, MD, and Benjamin O. Anderson, MD, both of the University of Washington in Seattle, in a commentary that accompanied the study.

“What will shift surgeon behavior toward higher quality, evidenced-based practices? It has long been recognized that making people aware of their own performance relative to peers can successfully improve the quality of their work,” Javid and Anderson wrote. “With increased visibility of one’s own performance relative to peers and evidence-based standards of practice, combined with the support of a respected credentialing body, such as the American Board of Surgery, toward the delivery and measurement of care, meaningful change is plausible.”

Other factors associated with a significantly lower propensity to use ALND included surgeon recommendation of a minimal margin width:

  • 1-5 mm: -0.10, 95% CI -0.43 to 0.22
  • no ink on tumor: -0.53, 95% CI -0.82 to -0.24

And participating in a tumor board:

  • 1%-9%: -0.25, 95% CI -0.55 to 0.05
  • >9%: -0.37, 95% CI -0.63 to -0.11

While ALND does reimburse at a higher rate, Morrow said she does not believe this to be “the major driver” of non-acceptance of Z0011.

“For so many years, removal of axillary nodes was considered an important part of local control and cure, and it is difficult for some to accept the concept that in the era of modern systemic therapy in patients getting breast RT as part of breast-conserving surgery that this is no longer true,” she said. “At the time we surveyed the surgeons in our study the 10-year results of Z0011 were not published, so a small proportion may have been waiting for those to be available.”

But, said Morrow, the main reason is likely that the Z0011 trial represented “a true change in our beliefs about breast cancer management and was very controversial initially.”

The study was funded by a grant from the National Cancer Institute.

Morrow and co-authors disclosed no conflicts of interest, nor did Javid and Anderson.

2018-07-12T18:00:00-0400
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Medpage Today

Breast Ca Surgeons Slow to Adopt 'Major' Practice Changes

High-volume surgeons had lower propensity for unneeded procedure

MedpageToday

  • by Deputy Managing Editor, MedPage Today

Despite guidelines from as far back as 2012 stating that axillary lymph node dissection (ALND) is no longer needed in certain early-stage breast cancer patients, most surgeons said they would still likely perform the more involved procedure, a survey study found.

For patients with clinically node-negative breast cancer and ≤2 sentinel nodes with macrometastasis, 49% of surveyed surgeons said they would "definitely or probably" recommend ALND in a patient with macrometastasis in a single node, reported Monica Morrow, MD, of the Department of Surgery at Memorial Sloan Kettering Cancer Center in New York City, and colleagues.

"Although avoidance of axillary dissection has been shown to be safe in high-quality studies, half of surgeons still do it routinely," Morrow told MedPage Today. "This practice is most common among surgeons not doing a lot of breast cancer, indicating a quality gap."

And 62.6% of surgeons said they would also opt for ALND if two sentinel nodes had macrometastasis.

"Z0011 clearly demonstrated axillary dissection was not necessary for those two scenarios," said Morrow.

First presented at a meeting in 2010, the American College of Surgeons Oncology Group Z0011 trial changed practice, revealing that ALND was no better than sentinel node biopsy (SNB) alone in terms of locoregional recurrence or survival among clinically node-negative breast cancer patients with metastases in one or two sentinel nodes. Following breast-conservation surgery, patients also received whole-breast radiation therapy (RT). Guidelines from both the National Comprehensive Cancer Network and the American Society of Clinical Oncology have both reflected the results of the trial since shortly after its publication in 2011.

"This issue needs to be addressed through targeted, clear education," said Morrow. "These findings were considered very controversial by some when first published, but are now confirmed in other studies and with longer follow-up, and this needs to be made clear to non-specialist surgeons."

The current study in JAMA Oncology invited 488 surgeons to participate in a survey of five clinical scenarios meant to tease out their acceptance of evidence-based guidelines for use of ALND.

In all 376 responded, 359 of whom filled out the clinical scenario portions of the surveys completely. Mean participant age was 53.7, and most were men (73.7%). A total of 37.8% of respondents were from low-volume centers, treating 20 breast cancer cases or fewer in the year prior to the survey. The rest were high-volume surgeons, with 29.8% seeing 21 to 50 cases and 28.7% seeing more than 50 in the prior year. Surgeons were found by searching data from the Surveillance, Epidemiology, and End Results (SEER) sites in Georgia and Los Angeles.

In multivariable analysis, surgeons were found to be have a significantly lower propensity to use ALND if they had a higher volume of breast cancer cases in the previous year:

  • 21-50 cases: -0.19, 95% CI -0.39 to 0.02
  • >51 cases: -0.48, 95% CI -0.71 to -0.24

"The finding that surgeons have been slow to adopt major practice changes is not new," wrote Sara H. Javid, MD, and Benjamin O. Anderson, MD, both of the University of Washington in Seattle, in a commentary that accompanied the study.

"What will shift surgeon behavior toward higher quality, evidenced-based practices? It has long been recognized that making people aware of their own performance relative to peers can successfully improve the quality of their work," Javid and Anderson wrote. "With increased visibility of one's own performance relative to peers and evidence-based standards of practice, combined with the support of a respected credentialing body, such as the American Board of Surgery, toward the delivery and measurement of care, meaningful change is plausible."

Other factors associated with a significantly lower propensity to use ALND included surgeon recommendation of a minimal margin width:

  • 1-5 mm: -0.10, 95% CI -0.43 to 0.22
  • no ink on tumor: -0.53, 95% CI -0.82 to -0.24

And participating in a tumor board:

  • 1%-9%: -0.25, 95% CI -0.55 to 0.05
  • >9%: -0.37, 95% CI -0.63 to -0.11

While ALND does reimburse at a higher rate, Morrow said she does not believe this to be "the major driver" of non-acceptance of Z0011.

"For so many years, removal of axillary nodes was considered an important part of local control and cure, and it is difficult for some to accept the concept that in the era of modern systemic therapy in patients getting breast RT as part of breast-conserving surgery that this is no longer true," she said. "At the time we surveyed the surgeons in our study the 10-year results of Z0011 were not published, so a small proportion may have been waiting for those to be available."

But, said Morrow, the main reason is likely that the Z0011 trial represented "a true change in our beliefs about breast cancer management and was very controversial initially."

The study was funded by a grant from the National Cancer Institute.

Morrow and co-authors disclosed no conflicts of interest, nor did Javid and Anderson.

2018-07-12T18:00:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



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