Survey of UK practice for management of breast cancer metastases to the neck

INTRODUCTION: Cervical metastases from breast carcinoma are rare and their management is controversial. Between 1987 and 2002 the American Joint Committee on Cancer (AJCC) staged patients with supraclavicular fossa nodal disease as M1 but the subsequent demonstration that patients with regional stage IV disease had better outcomes than visceral stage IV disease led to a reclassification of the former to stage IIIC in 2003. The literature remains inconsistent regarding the fate of these patients. Despite the attendant morbidity of treatment and lack of knowledge regarding long-term survival, we hypothesised that current practice varies in the UK and a unified approach does not exist. The aim of this study was therefore to determine current practice and opinion of both head and neck specialists and breast cancer clinicians in the UK. METHODS: Questionnaires were disseminated to 185 head and neck surgeons, breast surgeons and their oncology counterparts. These outlined a clinical scenario of a patient with a history of T3 primary breast cancer presenting with cervical and supraclavicular nodal metastases, with opinion being sought regarding the significance of this status and the individual’s practical approach to the problem. The extent of any proposed neck dissection was also explored. RESULTS: Of the 117 respondents, a noticeable variation in opinion was evident. Contrary to the current AJCC staging, 61% of clinicians felt that both level V and III metastases represented stage IV disease. There was a tendency towards aggressive surgical treatment with a third recommending comprehensive neck dissection despite a lack of evidence base. A disparity was noted between adjuvant treatments offered and the final pN stage. CONCLUSIONS: This study suggests that at present there is widespread inconsistency in the management of breast carcinoma cervical metastases in the UK. There is a need to unify practice with an evidence base in order to improve informed multidisciplinary decision making and, ultimately, patient care. This study goes some way to supporting multicentre collaboration in order to achieve that aim.