Surgeon Perspectives on Axillary Management Following Neoadjuvant Endocrine Therapy: Results from a Qualitative Substudy of the PELOPS Trial.

BACKGROUND

Evidence-based guidelines for axillary surgical management following neoadjuvant endocrine therapy (NET) are lacking. We aimed to explore decisions to perform or omit axillary lymph node dissection (ALND) in patients with clinically node-negative breast cancer and pathologic nodal disease after NET.

METHODS

Semi-structured interviews were conducted with surgeons from sites that participated in PELOPS (Palbociclib and Endocrine therapy for LObular breast cancer Preoperative Study; NCT02764541), a multi-institution clinical trial that randomized patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer to NET with or without palbociclib. Interviews were recorded, professionally transcribed, and thematically analyzed.

RESULTS

In total, 15 surgeons from four institutions participated. Self-reported demographics included six non-Hispanic white, four Asian, two Black, one Hispanic, two with ethnicity not reported; all female gender. The median number of years in practice was 4 (IQR 3-15.5), 93.3% reported an academic practice setting, and all reported breast-only practice. Five reported receiving 6-16 new patients per month, six reported 17-25, and four reported >25. Decisions to perform or omit ALND were informed by three main themes: (1) diagnostic versus therapeutic benefit of ALND, (2) appropriateness of extrapolating data from other patient populations such as upfront surgery or neoadjuvant chemotherapy to patients treated with NET; and (3) perspective of interdisciplinary colleagues and institutional preferences.

CONCLUSIONS

Based on these semi-structured interviews, future clinical trials of axillary management in hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer should be designed to intentionally include patients treated with NET as either receiving upfront surgery or post-neoadjuvant therapy to provide evidence-based guidelines for management of residual nodal disease after NET.

TRIAL REGISTRATION: clinicaltrials.gov, NCT02764541.