Quality assessment of neoadjuvant therapy use in breast conservation: barriers to implementation

Neoadjuvant systemic therapy (NST) for operable breast cancer can increase the options for conservative surgery in patients with breast cancer. We performed an analysis of a breast cancer outcomes database as a quality assessment of neoadjuvant therapy use in relation to breast conservative rate (BCR). Data were reviewed from a breast cancer database established to monitor outcomes of breast cancer surgery at a tertiary care breast cancer clinic. The frequency of NST-use was correlated to tumor size and BCR. Cause-specific factors for omitting NST in patients undergoing mastectomy for tumors 3 cm or greater were determined. NST was employed in 29 of 241 (12%) cases of invasive breast carcinoma treated surgically from 2003 to 2005. Although a significant decrease in BCR occurred in tumors >3 cm, NST was not frequently employed until tumors reached >5 cm. Defined contraindications to breast conservation (65%) and patient choice for mastectomy (30%) were the two most common reasons for omitting NST in tumors > or = 3 cm. Despite the initial appearance of NST under-utilization in tumors measuring between 3-5 cm, appropriate exclusion of patients not suitable for breast conservation and patient choice for mastectomy both emerged as leading factors for the omission of NST in this group. Use of NST is an important quality metric in optimizing breast conservation. Patient education and greater understanding of patient-related barriers to NST may help improve BCR.