Establishing Axillary Sentinel Lymph Node Biopsy (SLNB) for Early Breast Cancer in the United Kingdom: A Survey of the National Training Program.
Authors: Keshtgar M. , Keshtgar M. , Aresti N. 
Published: December 2010

Abstract
IntroductionThe UK National training programme (NEWSTART) for SLNB in breast cancer was established in 2004. This unique national educational initiative aimed at providing structured, standardised training with a focus on multidisciplinary team (MDT) delivery. Patient safety was the primary aim and central audit and validation was integral to the program.We conducted a national survey 4 years after its introduction with the aim of obtaining a snap shot of the training program and identifying if there are any common barriers that might limit participation and progression in SLNB training.MethodologyIn collaboration with the Association of Breast Surgeons (ABS) in the UK, paper and electronic questionnaires were sent to 400 registered surgeons. The questionnaire was divided into three sections, exploring the SLNB concept, training and post training experiences.ResultsMost (97%) of breast surgeons are convinced by the evidence for SLNB as standard of care for early breast cancer. 64% of respondents use SLNB to stage clinically node negative breast cancers, of whom 23% use it as a standalone procedure in their practice.The NewStart program begins with a theory day, which has been completed by 86% of respondants. Participants then either follow an apprentiship model of training (completed by 29%) or a proctorship model for which there is initially an in-house training phase (completed by 49%) and then a validation phase (completed by 41%). 38% of surgeons were dissatisfied with the time it takes to complete the in house training, and 87% with the time it takes to complete the validation phase. Logistical and funding issues were the main problems cited.The majority of surgeons (86%) use the recommended SLNB detection technique (combined isotope and blue dye), with 47% continuing to use the dual localisation method. 14% use either blue dye or isotope alone, without scintiscan imaging. Only 10% offer intra operative diagnosis, of which the majority (6%) use touch imprint cytology. These low figures are due to logistical constraints, including lack of on-site pathologists, funding and time. 31% included their results in their most recent surgical appraisal.ConclusionsThe NEW START program introduced and set a standard of care in a systematic method. It was unique in the sense that training was validated across a comprehensive national health service, translating specialist standards to every unit in the country, over a relatively short time frame. The majority of breast surgeons in the UK are convinced by the evidence for SLNB, and so most now use SLNB in their practice for staging clinically node negative breast cancer. Reasons for not conducting SLNB or IOD are logistical rather than lack of belief in the procedure. Barriers to uptake and progress were as expected - logistical and financial rather than attitudinal. The majority of respondents who completed their training did so within the anticipated time line. The majority of centres do not perform intra-operative assessment of the SLN due to lack of resources which means node positive patients have to undergo a second operation.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1020.