Effects of a regional guideline for completion axillary lymph node dissection in women with breast cancer to reduce variation in surgical practice: A qualitative study of physicians' views

• Published in: Breast (Edinburgh) 2016-10, Vol.29, p.126-131
• Main Authors: O'Brien, Mary Ann, Tsao, Miriam, Cornacchi, Sylvie D, Hodgson, Nicole, Reid, Susan, Simunovic, Marko, Mukherjee, Som D, Strang, Barbara, Thabane, Lehana, Lovrics, Peter J
• Format: Article
• Language: English
• Subjects: ACOSOG Z0011; Adult; Attitude of Health Personnel; Axilla; Breast Neoplasms - pathology; Breast Neoplasms - surgery; Female; Guideline Adherence; Hematology, Oncology and Palliative Medicine; Humans; Lymph Node Excision - psychology; Lymph Node Excision - standards; Lymph Nodes - pathology; Lymph Nodes - surgery; Male; Medical oncologist; Medical Oncology; Middle Aged; Practice Guidelines as Topic; Qualitative Research; Radiation oncologist; Radiation Oncology; Semi-structured interview; Sentinel Lymph Node Biopsy; Surgeon; Surgeons
• ISSN: 0960-9776; 1532-3080
• DOI: 10.1016/j.breast.2016.07.012

Abstract Background Recently the impact of completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy on significant outcomes has been questioned, leading to variation in surgical practice. To address this variation, a multidisciplinary working group created a regional guideline for cALND. We explored the views and experiences of surgeons, medical oncologists (MOs), radiation oncologists (ROs) in a qualitative study that examined guideline implementation in practice. Methods The Pathman framework (awareness, agreement, adoption and adherence) informed the interview guide design and analysis. Semi-structured interviews were conducted with MOs, ROs and surgeons and transcribed. Transcripts were coded independently by 2 members of the study team and analyzed. Disagreements were resolved through consensus. Results Twenty-eight physicians (5 MO; 6RO; 17S) of 41 (68% of those approached) were interviewed. Ten of 11 (91%) hospital sites (54% community; 46% academic) and all 4 cancer clinics within the region were represented. Twenty-seven physicians (96%) were aware of the guideline, with all physicians reporting agreement and general adherence to the guideline. Most physicians indicated nodal factors, age and patient preference were key components of cALND decision-making. Physicians from all disciplines perceived that the guideline helped reduce variation in practice across the region. There were concerns that the guideline could be applied rigidly and not permit individual decision-making. Conclusions Physicians identified breast cancer as an increasingly complex and multidisciplinary issue. Facilitators to guideline implementation included perceived flexibility and buy-in from all disciplines, while individual patient factors and controversial supporting evidence may hinder its implementation.