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Goyal A, Mann GB, Fallowfield L, Duley L, Reed M, Dodwell D, Coleman RE, Fakis A, Newcombe R, Jenkins V, Whitham D, Childs M, Whynes D, Keeley V, Ellis I, Fairbrother P, Sadiq S, Monson K, Montgomery A, Tan W, Vale L, Homer T, Badger H, Haines RH, Lewis M, Megias D, Nabi Z, Singh P, Caraman A, Miles E. POSNOC-POsitive Sentinel NOde: adjuvant therapy alone versus adjuvant therapy plus Clearance or axillary radiotherapy: a randomised controlled trial of axillary treatment in women with early-stage breast cancer who have metastases in one or two sentinel nodes. BMJ Open 2021; 11:e054365. [PMID: 34857578 PMCID: PMC8640630 DOI: 10.1136/bmjopen-2021-054365] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/03/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION ACOSOG-Z0011(Z11) trial showed that axillary node clearance (ANC) may be omitted in women with ≤2 positive nodes undergoing breast conserving surgery (BCS) and whole breast radiotherapy (RT). A confirmatory study is needed to clarify the role of axillary treatment in women with ≤2 macrometastases undergoing BCS and groups that were not included in Z11 for example, mastectomy and those with microscopic extranodal invasion. The primary objective of POsitive Sentinel NOde: adjuvant therapy alone versus adjuvant therapy plus Clearance or axillary radiotherapy (POSNOC) is to evaluate whether for women with breast cancer and 1 or 2 macrometastases, adjuvant therapy alone is non-inferior to adjuvant therapy plus axillary treatment, in terms of 5-year axillary recurrence. METHODS AND ANALYSIS POSNOC is a pragmatic, multicentre, non-inferiority, international trial with participants randomised in a 1:1 ratio. Women are eligible if they have T1/T2, unifocal or multifocal invasive breast cancer, and 1 or 2 macrometastases at sentinel node biopsy, with or without extranodal extension. In the intervention group women receive adjuvant therapy alone, in the standard care group they receive ANC or axillary RT. In both groups women receive adjuvant therapy, according to local guidelines. This includes systemic therapy and, if indicated, RT to breast or chest wall. The UK Radiotherapy Trials Quality Assurance Group manages the in-built radiotherapy quality assurance programme. Primary endpoint is 5-year axillary recurrence. Secondary outcomes are arm morbidity assessed by Lymphoedema and Breast Cancer Questionnaire and QuickDASH questionnaires; quality of life and anxiety as assessed with FACT B+4 and State/Trait Anxiety Inventory questionnaires, respectively; other oncological outcomes; economic evaluation using EQ-5D-5L. Target sample size is 1900. Primary analysis is per protocol. Recruitment started on 1 August 2014 and as of 9 June 2021, 1866 participants have been randomised. ETHICS AND DISSEMINATION Protocol was approved by the National Research Ethics Service Committee East Midlands-Nottingham 2 (REC reference: 13/EM/0459). Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN54765244; NCT0240168Cite Now.
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Affiliation(s)
- Amit Goyal
- Department of Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - G Bruce Mann
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Breast Cancer Trials, Newcastle, New South Wales, Australia
| | - Lesley Fallowfield
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Malcolm Reed
- Brighton and Sussex Medical School, Brighton, UK
| | - David Dodwell
- Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - Robert E Coleman
- Department of Oncology and Metabolism, Weston Park Hospital, Sheffield, UK
| | - Apostolos Fakis
- Research and Development, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Robert Newcombe
- Department of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Valerie Jenkins
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - David Whynes
- School of Economics, University of Nottingham, Nottingham, UK
| | - Vaughan Keeley
- Lymphoedema Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Ian Ellis
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Shabina Sadiq
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kathryn Monson
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tara Homer
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Heath Badger
- Breast Cancer Trials, Newcastle, New South Wales, Australia
| | | | - Mickey Lewis
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Daniel Megias
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Zohal Nabi
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Preetinder Singh
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Andrei Caraman
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, UK
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