A qualitative study exploring the views of global healthcare professionals towards de-escalation of axillary surgery in early breast cancer

Background: Axillary lymph node dissection (ALND) has significant morbidity without survival benefit. Despite recent trials suggesting ALND may be omitted in women with low-risk breast cancer with positive sentinel node biopsies (SLNB) or after complete response (pathCR) to neoadjuvant chemotherapy, ALND is often performed. This study interviewed global healthcare professionals (HCPs) about the facilitators and barriers to axillary de-escalation.

Methods: Semi-structured interviews were conducted with global breast HCPs. Interviews focused on management of axillary disease in clinically negative (cN0), and positive (cN1), settings. Interviews were transcribed verbatim and analysed using the Framework approach. Data were categorised into key themes. Interviews ceased with data saturation.

Results: Twenty-eight of 50 global HCPs responded to an e-mail invitation (52 %). Seven key themes were identified: guidelines and quality of evidence, technical details of axillary surgery, patient decision-making, clinician variation, adverse effects, selection criteria for de-escalation, and multidisciplinary team (MDT) factors. Generally, research-active surgeons and those from Europe expressed more confidence in the safety of axillary de-escalation. Those more cautious of omitting axillary clearance felt that results of further trials were needed. Key issues included conflict within MDTs (balancing staging depth against surgical morbidity), patient confusion when making this choice, a lack of decision-support tools, the complex nuances of axillary management and lack of detailed guidelines.

Conclusions: Axillary practice is highly variable and factors contributing to axillary overtreatment include insufficient confidence in, and knowledge of, existing research, poor guidelines, patient uncertainty, and conflict within the MDT. Decision support resources and updated guidelines are urgently needed.