title: Tumour bed clip localisation for targeted breast radiotherapy: compliance is proportional to trial-related research activity: tumour bed clip localisation in breast radiotherapy.
abstract: BACKGROUND
  In breast cancer, with the increasing use of intensity-modulated radiotherapy (IMRT), the need for accurate tumour bed localisation is paramount. We determined current practice of clip usage in patients referred to a regional centre for radiotherapy following breast conserving surgery. We also investigated whether participation of surgical units in IMRT trials, where tumour bed clip use is emphasised, was associated with clip insertion.
  
  
  METHODS
  A retrospective cohort study of consecutive CT planning images (n = 205), of breast cancer patients treated with radiotherapy following breast conserving surgery. Presence and number of clips; referring hospital and referring surgeon of the patient was recorded. This was correlated to previous participation of referring hospital to IMRT trials.
  
  
  RESULTS
  Of 196 eligible patients, 126 (64%) had clips sited, of which 15 (12%) had two or fewer clips. Five referring hospitals were high recruiters (≥14 patients), and five hospitals were low/non-recruiters (≤1 patient) to IMRT trials. Of patients from low/non-recruiting centres, 29 of 43 (67%) had clips omitted, compared to 41 of 153 (27%) from high-recruiting centres (p < 0.001). Median number of clips used in centres recruiting high numbers of patients was four, compared to zero in low recruiting centres. Ten of 31 referring surgeons routinely omitted clips.
  
  
  CONCLUSIONS
  Despite inclusion in national guidelines, clip insertion has not become routine in the UK in patients undergoing breast conserving surgery. However, hospitals involved in breast radiotherapy randomised controlled trials are more compliant with clip usage recommendations. Auditing of clip insertion should be considered as a quality control marker in breast surgery.
authors.affiliation: University of Manchester Department of Academic Surgery, South Manchester University Hospitals Trust, Southmoor Road, Manchester M23 9LT, UK. Electronic address: cliona.kirwan@manchester.ac.uk.
authors.forename: C C
authors.initials: CC
authors.lastname: Kirwan
authors.affiliation: Department of Surgery, Conquest Hospital, The Ridge, Hastings, East Sussex TN37 9RD, UK. Electronic address: walsarakbi@hotmail.com.
authors.forename: W
authors.initials: W
authors.lastname: Al Sarakbi
authors.affiliation: Department of Clinical Oncology, Christie Hospital, Manchester M20 4BX, UK. Electronic address: juliette.loncaster@christie.nhs.uk.
authors.forename: J
authors.initials: J
authors.lastname: Loncaster
authors.affiliation: Department of Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire GL53 7AN, UK. Electronic address: topoxforddoc@btinternet.com.
authors.forename: H Y
authors.initials: HY
authors.lastname: Chan
authors.affiliation: Clinical Research Centre, Dundee Cancer Centre, University of Dundee, Dundee DD1 9SY, UK. Electronic address: a.m.thompson@dundee.ac.uk.
authors.forename: A M
authors.initials: AM
authors.lastname: Thompson
authors.affiliation: Faculty of Health, Social Care & Education, Anglia Ruskin University, East Road, Cambridge BB1 1PT, UK. Electronic address: gcwishart@gmail.com.
authors.forename: G C
authors.initials: GC
authors.lastname: Wishart
mesh_terms: D001943:Breast Neoplasms / Q000532:radiotherapy / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D015412:Mastectomy, Segmental / Q000379:methods*; D018579:Patient Selection; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011880:Radiotherapy Planning, Computer-Assisted; D018714:Radiotherapy, Adjuvant; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods; D012106:Research / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013525:Surgical Instruments / Q000706:statistics & numerical data*
keywords: Breast cancer; Breast conserving surgery; Clips; Radiotherapy; Trials; Tumour bed