Current decisions on neoadjuvant chemotherapy for early breast cancer: Experts’ experiences in the Netherlands

https://doi.org/10.1016/j.pec.2018.07.012Get rights and content

Highlights

  • An accepted indication for NAC is down staging of the tumour to enable BCS (75%).

  • Contradictory, 21% argued that NAC increases the risk of invasive margins.

  • Only 64% routinely recommended NAC when systemic therapy was indicated.

  • WHO status of ≥2 was stated most frequently a reason to refrain from NAC.

Abstract

Purpose

To evaluate the opinion of surgical and medical oncologists on neoadjuvant chemotherapy (NAC) for early breast cancer.

Methods

Surgical and medical oncologists (N = 292) participating in breast cancer care in the Netherlands were invited for a 20-question survey on the influence of patient, disease, and management related factors on their decisions towards NAC.

Results

A total of 138 surgical and medical oncologists from 64 out of 89 different Dutch hospitals completed the survey. NAC was recommended for locally advanced breast cancer (94%) and for downstaging to enable breast conserving surgery (BCS) (75%). Despite willingness to downstage, 64% of clinicians routinely recommended NAC when systemic therapy was indicated preoperatively. Reported reasons to refrain from NAC are comorbidities (68%), age >70 years (52%), and WHO-performance status ≥2 (93%). Opinions on NAC and surgical management were inconclusive; while 75% recommends NAC to enable BCS, some stated that BCS after NAC increases the risk of a non-radical resection (21%), surgical complications (9%) and recurrence of disease (5%).

Conclusion

This article emphasizes the need for more consensus among specialists on the indications for NAC in early BC patients. Unambiguous and evidence-based treatment information could improve doctor-patient communication, supporting the patient in chemotherapy timing decision-making.

Introduction

Neoadjuvant chemotherapy (NAC) is an important initial strategy for the management of operable breast cancer (BC). In accordance with international guidelines, the Dutch national breast cancer guideline recommends NAC as an option for all patients aged <70 with an indication for systemic treatment, as similar overall and disease-free survival rates were demonstrated between preoperative and postoperative application of chemotherapy [[1], [2], [3], [4]]. These guidelines disclose that NAC may be used for large tumours (T3; >5 cm) to increase resectability and the rate of breast conserving surgery and axillary preserving surgery [5]. Besides, chemotherapy prior to breast surgery remains a valuable therapeutic approach for the assessment of biological anti-tumour activity and clinical efficacy of new treatments [6]. Furthermore, administration of NAC creates a time frame for testing on hereditary breast cancer and planning the final type of surgery, for example reconstruction surgery.

Despite these arguments in favour of NAC, large national and international variation in the application of NAC is observed between hospitals [7,8]. Previous research based on data from the NABON Breast Cancer Audit (NBCA) revealed that most variation between hospitals consists in the treatment of BC stage IIB with a national average of 40% NAC use. For BC stage III, the national average is 80%.

After adjustment for patient and tumour factors associated with the use of NAC, including hospital study participation, a considerable unaccountable variation still remained between all 89 Dutch hospitals [9,10].

Additional factors, such as clinician preferences and the level of shared decision-making, may play a role in the application of NAC [11]. Since it has been demonstrated that clinicians’ treatment recommendations exert one of the most powerful influences over patients’ preferences, the clinicians’ opinion on NAC is therefore of great importance [12]. Some specialists adhere firmly to their personal treatment preferences which may lie outside evidence of best practice or safety [13]. Consequently, differences in surgeons and medical oncologists’ opinions may lead to unwanted variation in treatment patterns. As options of chemotherapy timing are in equilibrium for overall and disease-free survival, but NAC also yields several advantages, it is important to gain insight in the observed variation of NAC application, as each patient indicated for NAC deserves a choice in chemotherapy timing. The aim of this study is to evaluate the current opinion of surgical and medical oncologists in the Netherlands on the use of NAC and their decisions towards NAC in early breast cancer.

Section snippets

Participants

On November 11, 2015, an invitation for an online survey was sent by mail to 575 surgical and medical oncologists, invited by the network of the NABON Breast Cancer Audit (NBCA), covering all Dutch hospitals that are involved in breast cancer care. A reminder was sent to non-respondents 3 weeks later and the survey was closed on January 8th, 2016.

Demographics of participating hospitals were derived from the NBCA dataset. The surgical volume of a hospital was defined as the mean annual number of

Results

A total of 292 clinicians opened the online program, of whom 138 clinicians from 64 out of 89 Dutch hospitals completed the survey, leading to a response rate of 473%. Of 138 respondent clinicians, 70 surgical oncologists (43% female, 57% male) and 68 medical oncologists (59% female, 41% male) participated in the survey. The respondents had been in clinical practice for a median of 12 years (range 1–35). The number of annually treated breast cancer patients varied from 50 patients for medical

Discussion

This survey depicts the opinion of 138 Dutch surgical and medical oncologists from 64 out of 92 hospitals in the Netherlands on NAC in BC. Despite an international trend of increasing implementation for NAC in patients with early BC and the relatively high standard of care in the Netherlands, considerable variation in the use of NAC still exists between hospitals.

Respondents rated LABC as the most distinguished indication for NAC, in accordance with Dutch and international breast cancer

Role of the funding source

We would like to thank the Dutch Cancer Society (KWF) for their financial support by providing the grant on “Research on (improving) quality of oncological care – 2015”. The Dutch Cancer Society is a nation-wide organization for cancer related work in the Netherlands. It’s supported by over 1 million donors and receives no money from the government.

Conflict of interest

Non-declared.

Acknowledgements

We would like to thank all surgeons and medical oncologists for their participation in the survey.

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