Megan Kruse, MD, Says Oncologists Need Better Messaging Surrounding Omission of SLNB

In this exclusive MedPage Today video analysis, Megan Kruse, MD, of Cleveland Clinic, analyzes a study reported at the most recent ASCO Quality Care Symposium by Christina Ahn Minami, MD, MS, and colleagues at Brigham and Women’s Hospital in Boston, on oncologists’ views about sentinel lymph node biopsy in certain breast cancer patients.

Following is a transcript of her remarks:

I’m Megan Kruse, breast medical oncologist at Cleveland Clinic. And today I will be talking about an abstract that was presented at the 2021 ASCO Quality Care Symposium by Drs. Miami et al., the group of breast surgeons at Dana Farber.

So this abstract covers oncologists’ perspectives on omission of sentinel lymph node biopsy in women over the age of 70, with early-stage hormone receptor positive breast cancer. And the reason that this topic of interest was brought up by the investigators is because in the Society of Surgical Oncology [recommendations in the] Choosing Wisely campaign, the omission of sentinel lymph node biopsy for this group of patients is actually a recommended clinical management step.

And the reason for this is there is good data from the CALGB 9343 study, which was actually a study looking at the inclusion or omission of radiation for women in this over 70 year old age group, with early-stage low-risk, hormone-positive breast cancer.

And in that study women were actually discouraged from having axillary lymph node surgery, and we know that about 60% of patients did not have axillary nodal assessment. And yet the overall survival outcomes were excellent. There was really no impact on survival whether patients received the axillary node surgery or not, or actually if they receive radiation or not.

So based on this, we had the recommendation that came into the Choosing Wisely campaign. Now, despite that recommendation being out for a while now, we know that about 80% of women who fall into this eligible group of patients actually still have sentinel lymph node evaluation done at the time of their breast cancer surgery. So again, the investigators sought to figure out why we have a good-quality recommendation, and yet it’s not really making its way into clinical practice.

So in this study they sought to get the expert opinions and perspectives for a variety of oncologists who take care of breast cancer patients. This included surgical oncologists, radiation oncologists, and medical oncologists. And the group of oncologists who participated actually had a wide variety of practices. They were in practice for a median of 12 years, but saw anywhere between 10% and 100% breast cancer patients in their clinics. And the group of clinicians that were surveyed also represented a variety of clinical practice settings in terms of academic and community practice.

And actually what they found is that the participants were willing and could identify that this was a recommendation, and that they were at least willing to consider it in theory for their patients, but noted that the actual decision and clinical practice is far more complex, and usually has to do with a patient’s fitness for surgery and other medical therapy. And also patients’ perspectives and desires for their surgical management.

And what was interesting among the radiation oncologists and medical oncologists that were surveyed was that they actually found themselves potentially making extra management recommendations based on this omission of sentinel lymph node biopsy if it were to actually occur in clinical practice.

So what did that look like? That actually meant potentially including high tangents in the radiation plan, or avoiding the option of partial breast radiation. And for the medical oncologist, we found that these patients were more likely to potentially get offered some gene expression assays — like OncotypeDX, for example — to assess the biologic risk of their cancer when you didn’t have that anatomic risk that was able to be assessed via sentinel lymph node biopsy.

So I think, what this highlights is that even though a lot of our recommendations can be founded on good data, their application and clinical practice can vary based on the clinical practice setting, the type of patient seen, and the provider’s own comfort level with that recommendation.

And I can tell you from my perspective as a medical oncologist that I would feel similarly about making this decision as an aggregate of different pieces of information, not solely based on the patient’s tumor staging as well as their age, but taking into account their fitness. And actually one of the most important factors being their willingness to adhere to adjuvant endocrine therapy. Because that was assumed in the CALGB study that formed the basis for this recommendation, or at least a large portion of it.

And we know, in clinical practice, that adherence to endocrine therapy can be very challenging, especially among this older age group where patients may prioritize quality of life over length of life or quantity of life. And I think that’s a conversation that many of us have daily in our clinical practices.

So this really opens the door to have more conversation about how the guidelines are adopted, or sort of these best practices that come in the Choosing Wisely campaigns. And if we feel strongly about it as an oncologic community, how do we get that message out further so more patients are treated in the way of this guideline, so that we can then go and further study the outcomes in that population moving forward.

Read the review here.

Read an interview with Christina Minami, MD, about it here.

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