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National Practice Questionnaire on management of breast cancer locoregional recurrence

Management of breast cancer patients who present with locoregional recurrence was highlighted as a key research priority at the Association of Breast Surgery Gap Analysis meeting in 2019. Breast cancer locoregional recurrence is defined as breast cancer recurrence (invasive or DCIS) within the conserved breast, the ipsilateral skin or chest wall following mastectomy, or in the ipsilateral regional lymph nodes (axilla, supra- or infra-clavicular, or internal mammary nodes). Currently there is no UK specific guideline on how these patients should be managed.

This questionnaire will aim to evaluate how UK breast units are managing patients with LRR. This will be followed by the MARECA study- National Study of Management of Breast Cancer Locoregional Recurrence and Oncological Outcome. This is a prospective observational multicentre cohort study which will describe the current management and prognosis of patients diagnosed with breast cancer locoregional recurrence in the UK.

We would like you to answer the National Practice Questionnaire within your entire multidisciplinary team (maybe before or after the multidisciplinary meeting when all team members are present). The questionnaire will take approximately 20 minutes to complete and consists of questions about the number of cases your unit deals with followed by some scenario based questions designed to capture data on practice variation and areas of uncertainty.

The first section (basic unit information) could be completed in advance of the multidisciplinary team meeting in order to ease time constraints on the multidisciplinary team members.

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* 1. Basic Unit Information

Please state the name of the participating hospital.

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* 2. Please state the name, email address, and job title of the person entering data for your unit's questionnaire.

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* 3. Does your unit treat patients referred from the breast screening programme?

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* 4. How many new breast cancers (invasive cancer and DCIS) do you manage per calendar year?

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* 5. Does your unit keep a prospective database of patients diagnosed with breast cancer locoregional recurrence?

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* 6. Does your trust submit data on breast cancer recurrence to a national database?

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* 7. As an estimate, how many patients with locoregional recurrence (without distant metastasis) do you manage at your unit per year?

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* 8. As an estimate, how many patients with locoregional recurrence (with distant metastasis) do you manage at your unit per year?

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* 9. Practice questionnaire scenarios
MDT attendance for the National Practice Questionnaire

Please state the number of participating MDT members

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* 10. Scenario 1. Diagnosis and staging investigations

A 50 year old patient presents with 3cm invasive recurrence in the ipsilateral breast after previous breast conserving surgery (BCS) and sentinel lymph node biopsy (SLNB) 3 years ago. The recurrence is in the same quadrant and has same molecular receptor status as the original cancer. The tumour does not involve the skin or chest wall. Does your unit perform an axillary ultrasound scan (USS)?

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* 11. If this patient had previous axillary node clearance (ANC) instead of SLNB, does your unit perform an axillary USS?

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* 12. Would your unit offer staging investigations for this patient?

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* 13. If yes, which staging investigations would be recommended (please tick all that apply)?

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* 14. If this patient had instead presented with an invasive recurrence in a different breast quadrant with a different molecular receptor status as the original cancer, would your unit offer staging investigations?

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* 15. If this patient was found to have concurrent distant metastasis, would your MDT offer resection of the in-breast recurrence?

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* 16. Scenario 2. Surgery to the breast

A 76 year old patient underwent BCS and SLNB 10 years ago, followed by whole breast radiotherapy (WBRT). The previous histology had shown a 10mm area of grade 2 invasive ductal carcinoma (IDC) which was ER strongly positive and Her-2 negative. She had 3 nodes removed at SLNB of which none were positive. She had 5 years of letrozole treatment after surgery.

She now presents with a 1cm grade 1 ER+HER2- IDC 3 cm away from the primary scar. She wears a DD cup bra size and has good symmetry. She is fit and well. Would your MDT offer repeat BCS for this patient?

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* 17. If this patient had not received previous WBRT (she was PRIME 2 compliant), would your MDT offer repeat BCS?

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* 18. If your MDT offers repeat BCS for patients who had previously been treated with BCS and radiotherapy, does your MDT offer repeat breast radiotherapy?

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* 19. Scenario 3. Axillary management

A 40 year old patient underwent BCS and SLNB for a 2.5cm grade 3 IDC 3 years ago in the upper outer quadrant. Disease was resected with a clear margin and none of 2 lymph nodes contained any cancer. The disease was ER+ and Her2 negative. She had post-operative WBRT plus boost, chemotherapy, and 5 years of tamoxifen.

She now presents with an in-breast invasive local recurrence close to the primary scar measuring 10mm. Her pre-operative axillary assessment is benign clinically and on ultrasound. Staging is clear.  What is your MDT’s preferred mode of axillary management?

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* 20. If this patient undergoes repeat SLNB and no SLN can be identified using your unit’s standard tracer technique, how do you proceed?

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* 21. Scenario 4. Adjuvant treatment and patient follow up

A fit and well 65 year old patient was treated with mastectomy and SLNB for a grade 3 node negative ER+HER2- 3cm IDC 7 years ago. She received adjuvant chemotherapy (3 cycles of anthracycline + cyclophosphamide, then 3 cycles of taxane) due to high Oncotype Dx score and completed 5 years of endocrine therapy. She did not require post mastectomy radiotherapy.

She now presents with a 1.5cm mastectomy skin flap invasive recurrence which is mobile. Staging is clear and she undergoes wide local excision of the skin flap and axillary surgery. Her resection margins are clear with negative lymph nodes. If this recurrent cancer was a grade 2 ER+HER2- IDC, would your MDT recommend adjuvant chemotherapy for this patient?

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* 22. If your unit offers Ki-67 testing, does your unit perform Ki-67 test on the recurrent cancer in order to inform adjuvant chemotherapy decision-making for this patient?

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* 23. Would your MDT recommend radiotherapy to the chest wall for this patient?

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* 24. For this scenario, If the patient had instead developed the ER+HER2- local recurrence 3 years after her primary cancer surgery (i.e. whilst still on adjuvant endocrine therapy), what adjuvant treatment(s) would your MDT recommend?

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* 25. For this scenario, if at the time of the recurrent cancer (ER+HER2- IDC) resection, she was instead found to have 1/3 macrometastasis in her axillary lymph nodes, would your MDT recommend adjuvant chemotherapy for this patient?

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* 26. For this scenario, if the patient had instead developed a recurrent cancer which was grade 3 triple negative IDC (and node negative), would your MDT recommend adjuvant chemotherapy for this patient?

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* 27. Patient follow up policy

Are patients in your unit followed up in the clinic after treatment for breast cancer locoregional recurrence?

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* 28. What is the total duration of clinic follow up for these patients?

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* 29. Thank you very much for taking time to complete the survey. We are in the process of setting up a national study of management of breast cancer locoregional recurrence and oncological outcome (the MARECA study). We welcome participation from all UK breast units. Please email the study team (leedsth-tr.themarecastudy@nhs.net) to register your interest. We especially welcome participation from trainees.

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