Surgeons’ preferences for using sentinel lymph node biopsy in patients with ductal carcinoma in situ

Claudia J. C. Meurs, Janine A. van Til, Marian B. E. Menke-Pluijmers, Stefanie de Vet, Sabine Siesling, Pieter J. Westenend



There is a large variation between Dutch hospitals in the use of Sentinel Lymph Node Biopsy (SLNB) in patients with a biopsy diagnosis of Ductal Carcinoma in Situ. The aim of our study was to investigate whether this variation might be explained by preferences of surgeons, organisational factors or the influence of patients preferences


Of the patients with a preoperative diagnosis of Ductal Carcinoma in Situ (DCIS), 20 to 25% will have a final diagnosis of invasive breast cancer after surgery [1–3]. For this reason, staging with Sentinel Lymph Node Biopsy (SLNB) is considered in patients thought to be at high risk of a diagnosis of invasive breast cancer. Several international guidelines have been developed to select patients with an increased risk [4, 5]. Previous studies, showed differences between hospitals in the use of axillary evaluation or SLNB for DCIS [6, 7].



A cross sectional web survey was done in the Netherlands. A total of 260 surgeons, from 77 hospitals were invited by e-mail. Two reminders were send. The survey instrument consisted of best-worst scaling (BWS) scenarios, questions on ranking of patient and tumour characteristics, background information and organisational factors (see S1 File). The BWS scenarios and the ranking questions were preference questions and therefore answers were included of all surgeons who completed the survey. For the background characteristics and the organizational factors we used the answers of the first surgeon of a specific hospital who completed the survey. We aimed at a response rate of 30% by individual respondents covering at least 50% of the invited hospitals. The survey was done online with the program LimeSurvey.


Respondents characteristics

The questions about the background characteristics and the organisational factors were filled out by 81 surgeons (of 260, 31%) representing 57 different hospitals (of 77, response rate 74%). Of these, 24 were excluded since only one questionnaire on organisational factors per hospital was included. Table 1 shows the background characteristics that were provided by surgeons, representing 57 hospitals.


The aim of our study was to determine whether the inter-hospital variation in the use of SLNB in the Netherlands could be explained by the preferences of surgeons, organisational factors or the influence of patient wish. The preference analyses by means of BWS scenarios and ranking showed both that surgeons considered suspicion of an invasive component at biopsy and the DCIS grade to be the most important risk factors. We did not find an association between use of SLNB and organizational factors.


The authors thank Brenda Voorthuis and Karin Groothuis-Oudshoorn of the department of Health Technology and Services Research of the University of Twente for the statistical advice, Kelly de Ligt of the Netherlands Comprehensive Cancer Organisation for her assistance in distributing the survey and the respondents for participating in the survey.

Citation: Meurs CJC, TilJAv, Menke-Pluijmers MBE, Vet Sd, Siesling S, Westenend PJ (2022) Surgeons’ preferences for using sentinel lymph node biopsy in patients with ductal carcinoma in situ. PLoS ONE 17(6): e0269551.

Editor: James A.L. Brown, University of Limerick, IRELAND

Received: August 23, 2021; Accepted: May 24, 2022; Published: June 6, 2022

Copyright: © 2022 Meurs et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The dataset is available in the following repository: Data Archiving and Networked Services (DANS), The data are available by two separated datasets: a dataset for the background and organisational factors and a dataset for the BWS scenarios and the ranking.

Funding: C. Meurs Grant number SLP2015-7769. Dutch Cancer Foundation The funder had no role in the design of the study, analysis, interpretation of results and in writing the manuscript.

Competing interests: The authors have declared that no competing interests exist.

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