Abstract OT1-09-02: ATNEC: A multicentre, randomized trial investigating whether axillary treatment can be avoided in T1-3N1M0 breast cancer patients with no residual cancer in the axillary lymph nodes after neoadjuvant chemotherapy
Authors: Goyal Amit , Nicholls Sophie , Marshall Andrea , Hammonds Natalie , Wheatley Duncan , Elsberger Beatrix , Rose Janice , Edwards Helen-Teresa , Butt Roeum , Shaaban Abeer , Puri Shama , Ahmed Samreen , Homer Tara , Vale Luke , Bruce Julie , Gasson Sophie J. , Higgins Helen , Dunn Janet A. 
Published: March 2023

Background: For patients who are node positive at presentation and are found to have a complete nodal tumour response (ypN0) post-neoadjuvant chemotherapy (NACT), we do not yet know whether local axillary therapy can be modified based on the response to NACT. ATNEC addresses whether axillary treatment can be de-escalated, post-surgery, in T1-3N1M0 breast cancer patients who have no residual nodal disease post-NACT. Methods: Design: ATNEC is a phase III, randomized (1:1), multi-centre trial, with embedded economic evaluation. Patients with proven axillary node metastases on needle biopsy receive NACT followed by sentinel node biopsy (SNB). If the sentinel nodes have converted to ypN0, ATNEC randomizes patients to axillary treatment (nodal radiotherapy [ART] or axillary nodal clearance [ANC]) vs. no further axillary treatment. Stratification: Institution, type of surgery (breast conserving surgery vs mastectomy), receptor status (triple negative vs HER2 positive vs ER positive and/or PR positive and HER2 negative). Inclusion criteria: • Age ≥ 18 • Male or female • T1-3N1M0 breast cancer at diagnosis (pre-NACT) • FNA or core biopsy confirmed axillary nodal metastases at presentation • ER and HER2 status evaluated on primary tumour • Received standard NACT as per local guidelines • Imaging of the axilla to assess response to NACT • Dual tracer SNB post-NACT and at least 3 nodes removed (sentinel nodes and marked node). o If a single tracer is used, the patient is eligible if the involved node is marked pre-NACT and at least 3 nodes removed (including the marked node) o If axillary node sampling is performed following failed localization of sentinel nodes, patient is eligible if at least 3 nodes removed (including the marked node). o If node is not marked, or marked node is not removed, patient is eligible if the histology report shows evidence of down-staging with complete pathological response in at least one node of the 3 removed nodes. • No evidence of nodal metastases post-NACT (ypN0) Exclusion criteria: • Bilateral invasive breast cancer • SNB prior to NACT • Previous ipsilateral axillary nodal surgery • Previous cancer within last 5 years or concomitant malignancy Aims: To assess whether omitting further axillary treatment (ART or ANC) for patients with early stage breast cancer and axillary nodal metastases on needle biopsy - who post NACT have no residual nodal disease on SNB (ypN0) - is non-inferior to axillary treatment in terms of disease-free survival, and whether lymphoedema is reduced at 5 years. Statistical methods: All analyses will be carried out on an intention-to-treat basis to preserve randomization, avoid bias from exclusions and preserve statistical power. Radiotherapy Quality Assurance: ATNEC has in-built radiotherapy QA coordinated by National Radiotherapy Trials QA (RTTQA) group. The RTQA monitors trial protocol compliance ensuring clinical outcomes reflect differences in randomization schedules rather than departures from the protocol. ATNEC is the only trial in the UK that offers QA for IMC radiotherapy. Screening Data: ATNEC collects screening data to monitor acceptance rates and reasons why patients decline the trial to identify ways to improve recruitment. Screening data until 30-Jun-22 shows that 69% of eligible patients were approached (244/354) and, of those approached, 45% were consented (109/244). For the 81 patients who declined, the most common reasons were; preference for axillary treatment (31%), preference for no axillary treatment (10%), no reason documented (23%) and ineligibility (21%). ClinicalTrials.gov: NCT04109079 Target accrual: 1900 Target sites: 100 Trial Status: Recruiting. As of 30-Jun-22: 52 sites open, 158 patients enrolled, 54 randomised. ATNEC is open to new sites and international collaboration.

Citation Format: Amit Goyal, Sophie Nicholls, Andrea Marshall, Natalie Hammonds, Duncan Wheatley, Beatrix Elsberger, Janice Rose, Helen-Teresa Edwards, Roeum Butt, Abeer Shaaban, Shama Puri, Samreen Ahmed, Tara Homer, Luke Vale, Julie Bruce, Sophie J. Gasson, Helen Higgins, Janet A. Dunn. ATNEC: A multicentre, randomized trial investigating whether axillary treatment can be avoided in T1-3N1M0 breast cancer patients with no residual cancer in the axillary lymph nodes after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT1-09-02.