Decision-Making Patterns for Clinically Node-Positive, Hormone Receptor-Positive, HER2-Negative Early Breast Cancer: Insights From a Survey of Breast Cancer Experts

Abstract

Purpose: In hormone receptor (HR)-positive, human epidermal growth factor receptor 2-negative (HER2-) breast cancer, the omission of chemotherapy has become a viable option for select patients. However, when lymph node (LN) metastasis is suspected at diagnosis, the optimal initial treatment strategy (upfront surgery, neoadjuvant chemotherapy, or genomic testing) remains controversial. This study aimed to assess the preferences of multinational breast cancer specialists and to identify the factors influencing clinical decisions in this setting. Methods: A cross-sectional survey was conducted among breast cancer specialists at two time points: November 2023 (via the Korean Breast Cancer Society) and April 2024 (following the Asian Breast Cancer Network meeting at Global Breast Cancer Conference 2024). The questionnaire presented 18 case scenarios that reflected varying patient ages, tumor sizes, nodal involvement, and pathological features. Respondents selected their preferred initial treatment strategy. Consensus was defined as >= 60% agreement. Univariate and multivariate logistic regression analyses were performed to identify the demographic factors associated with responses in the non-consensus scenarios. Results: A total of 189 responses were analyzed. Consensus was consistently observed in postmenopausal patients and in cases involving small low-grade tumors with limited nodal suspicion. However, the responses varied between peri-and pre-menopausal patients, particularly in the intermediate-risk scenarios. Multivariate analysis revealed that clinician specialty, nationality, affiliation, and experience significantly influenced treatment choice. Notably, clinicians from other Asian countries and medical oncologists showed a greater preference for upfront surgery than for neoadjuvant chemotherapy in younger patients with aggressive tumor features. Conclusion: The findings reveal both consensus and variability in clinical decision-making for HR+HER2-breast cancer with suspected LN involvement among multinational breast cancer specialists. This underscores the need for enhanced international collaboration and clear guidance in intermediate-risk settings. The incorporation of diagnostic tools such as multigene assays may further support individualized treatment decisions.