Assessment of Oncologists’ Perspectives on Omission of Sentinel Lymph Node Biopsy in Women 70 Years and Older With Early-Stage Hormone Receptor–Positive Breast Cancer

Key Points Question What are surgical, medical, and radiation oncologists’ perspectives on the omission of sentinel lymph node biopsy (SLNB) in women 70 years and older with early-stage hormone receptor–positive breast cancer? Findings In this qualitative study involving semi-structured interviews of 29 surgical, medical, and radiation oncologists, the decision to omit SLNB involved nuanced patient- and disease-level factors. Wide variation was observed in oncologists’ perspectives on SLNB omission recommendations and supporting data, and participants’ statements suggest that the multidisciplinary nature of cancer care may increase oncologists’ anxiety regarding omission of SLNB. Meaning This study’s findings suggest that interventions aimed at educating physicians, facilitating preoperative multidisciplinary conversations, and improving patient-physician communication may help to appropriately decrease SLNB rates.


Introduction
Thank you for taking the time to speak with me today. We are speaking with physicians to better understand their perspectives on axillary evaluations in older women with breast cancer. Our discussion today will help inform a survey that will explore issues and attitudes towards the possible omission of axillary evaluation in older women with early-stage hormone-positive breast cancer. There are no right or wrong answers in our discussion today, as we are here to better understand your experience and perspectives on the topic at hand. This interview will be recorded and takes, on average, twenty minutes. Recordings will not be shared with your colleagues, patients or families, or with anyone else outside the research team. I want to be sure that you understand that being part of this interview is voluntary, you can opt to not answer questions or end the conversation at any time.
We appreciate your participation in this study.

Obtain informed consent
Do you have any questions before we begin the interview?
Begin recording

I. Demographic Information
First off, could I get some baseline information about you? 1) How many years have you been in practice?
2) How would you describe your practice with regards to being academic or community-based or a hybrid model?
3) In what field/specialty, if any, are you board certified? 4) What fellowship training do you have, if any? 5) What is the scope of your surgical practice? a) What percentage of your practice is breast surgery? b) Approximately how many women do you see a month who are over 70, with clinically nodenegative, hormone-positive breast cancer? c) How do you usually clinically evaluate the axilla in these women (i.e. physical exam and/or U/S?)

If surgeon routinely uses U/S, ask how they define being "clinically node-negative"
d) How do you usually surgically evaluate the axilla in these women (i.e. ALND or SLNB)?

If surgeon usually performs ALND, ask for further explanation
For the next set of questions, I am asking you to focus specifically on the management of patients 70 and older, with clinically node-negative, hormone-positive breast cancer. Possible probe:

II. Current Practice
-Do you turn to any particular published data that guide your opinions?

14)
Are there any external factors (like financial pressure or incentive, or regulations) that influence your approach to axillary evaluation?
Possible probes: -Do financial incentives or disincentives play a role? -Or institutional pressures or regulations? -What about malpractice environment?

If surgeon unaware of trial data supporting omission of axillary evaluation:
We are curious about use of axillary evaluation in this patient population because there are data from randomized controlled trials demonstrating that axillary evaluation could be safely omitted in this population without compromising survival, and with an increase in axillary recurrence rate of only 3%. In 2016, the Society of Surgical Oncology, the SSO, released a guideline counseling against routine use of axillary evaluation in this patient population. 22) Who is usually part of the decision-making process around axillary evaluation?
-For example, do you think your medical or radiation oncology colleagues would like to weigh in on this decision?

Introduction
Thank you for taking the time to speak with me today. We are speaking with physicians to better understand their perspectives on axillary evaluations in older women with breast cancer. Our discussion today will help inform a survey that will explore issues and attitudes towards the possible omission of axillary evaluation in older women with early-stage hormone-positive breast cancer. There are no right or wrong answers in our discussion today, as we are here to better understand your experience and perspectives on the topic at hand. This interview will be recorded and takes, on average, twenty minutes. Recordings will not be shared with your colleagues, patients or families, or with anyone else outside the research team. I want to be sure that you understand that being part of this interview is voluntary, you can opt to not answer questions or end the conversation at any time.
We appreciate your participation in this study.

Obtain informed consent
Do you have any questions before we begin the interview?

I. Demographic Information
First off, could I get some baseline information about you?

1) How many years have you been in practice?
2) How would you describe your practice with regards to being academic or community-based or a hybrid model?
3 For the next set of questions, I am asking you to focus specifically on the management of patients 70 and older, with clinically node-negative, hormone-receptor positive breast cancer. -For example, is your opinion ever elicited pre-operatively by the surgeons that you work with? 8) What happens in a situation where there is disagreement about whether axillary evaluation is needed?

II. Current Practice
-have you ever found it necessary to ask the surgeon to take the patient back to the OR for axillary evaluation? 9) How would you describe the usually approach to the decisions around evaluating the axillary in this patient population?
-Who is usually part of the decision-making process around axillary evaluation?
-What patient and disease factors play a role in the decision to evaluate the axillary? We are curious about use of axillary evaluation in this patient population because there are data from randomized controlled trials demonstrating that axillary evaluation could be safely omitted in this population without compromising survival, and with an increase in axillary recurrence rate of only 3%. In 2016, the Society of Surgical Oncology, the SSO, released a guideline counseling against routine use of axillary evaluation in this patient population.

18) What are your initial reactions to hearing this information?
How, if at all, does this information impact your consideration around axillary evaluation?
19) Can you describe any factors or reasons that might keep you from supporting omission of axillary evaluation in this population?

If oncologist IS aware of trial data or SSO guideline:
20) To what extent do you agree or disagree with the Society of Surgical Oncology's Choosing Wisely 2016 recommendation: "Don't routinely use sentinel node biopsy in clinically node negative women >70 years of age with hormone positive invasive breast cancer?"

Probes:
a) What were your initial reactions to this recommendation?
-What do you think of the quality of evidence supporting this practice? b) What do you think of the clarity of the recommendation? -How would you interpret this recommendation? 21) What is your opinion of the SSO as a source for practice recommendations?