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Contact Information:

Dr Jessica Foster
+44 (0)121 414 9021
small@trials.bham.ac.uk


Study Location:

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Be Part of Research - Trial Details - A study for women who have small breast cancers found by screening, comparing removal of the cancer by standard surgery with a smaller procedure, which is more like a biopsy

A study for women who have small breast cancers found by screening, comparing removal of the cancer by standard surgery with a smaller procedure, which is more like a biopsy

Medical Conditions

Breast Cancer


This information is provided directly by researchers, and we recognise that it isn't always easy to understand. We are working with researchers to improve the accessibility of this information. In some summaries, you may come across links to external websites. These websites will have more information to help you better understand the study.


Start dates may differ between countries and research sites. The research team are responsible for keeping the information up-to-date.  

The recruitment start and end dates are as follows:

15 Nov 2019 30 Jun 2025

Interventional

Intervention Type : Other
Intervention Description : STUDY DESIGN & JUSTIFICATIONThe SMALL trial is a prospective randomised, two-arm, multi-centre trial. The recruitment target is 800 patients. It is anticipated that 70 U.K. sites will be opened to recruitment. Patients will be randomised in a 1:2 ratio to undergo either standard surgery and sentinel lymph node biopsy or vacuum-assisted excision (VAE), and it is expected that this will take place within 31 days of randomisation. All patients will be followed up via the recruiting site for 5 years post-randomisation. Further long-term follow-up data may be collected by the data linkage services.

This study aims to address the issue of possible over-treatment of small screen-detected breast cancers by assessing whether such cancers can be treated with minimally-invasive vacuum excision, in the context of a randomised clinical trial. In order to be practice changing, it will be necessary to demonstrate that not only is there an acceptable local recurrence risk associated with VAE followed by radiotherapy and endocrine therapy, but also that there is not an excess requirement for additional procedures in the VAE arm, in case of radiologically-determined incomplete excision.

The total number of patients to be recruited with the 1:2 allocation ratio in favor of VAE is 800 (267 surgery, 533 VAE). The total number required for the re-excision comparison was 762, and this has been inflated by 5%. This will ensure that we have sufficient patients for the single arm investigation of local recurrence rates with VAE, and allow for possible drop-outs.

No formal interim analysis is planned. The final analysis following the initial procedure will be conducted 3 months following the completion of recruitment. This will ensure that all patients have undergone their randomised procedure and been assessed for re-excision. The analysis of complications arising from surgery or VAE will also be conducted at this point. Analysis of the local recurrence free survival and all remaining secondary outcomes will be conducted 3 months after all patients have completed 3 years of annual mammography following randomisation.

PATIENT PATHWAYPatients enrolling in the trial will recently have attended their local NHS Breast Screening Unit following recall for assessment of a mammographic abnormality identified on their routine screening mammograms. At this time, where possible, the local screening unit will supply potentially eligible patients with a copy of the brief introductory Patient Information Leaflet (PIL), and this will be given either with the invitation to attend for assessment or at the clinic appointment. This PIL aims to provide information to prepare patients for a possible invitation to participate in a research study at an early stage in their pathway. They will also receive information regarding the Information Study (the optional recruitment intervention) at this stage.

The subsequent patient pathway will be as follows:1. Eligible patients will attend clinic to receive the results of their biopsy2. They will be invited to take part in the optional Information Study3. Patients will complete and sign the optional Information Study Informed Consent Form, if applicable4. If the patient consents to participate in the Information Study, the subsequent trial discussion may be audio-recorded5. Patients agreeing to participate in SMALL will complete and sign the Informed Consent Form for the main trail6. Patients will complete baseline Quality of Life questionnaires7. Randomisation by the research team8. Patient attends for either standard surgery or VAE according to randomised allocation9. Patients in the VAE arm will have post-procedure mammography on the same day as their procedure10. After treatment, patient results including histopathology and post-procedure imaging will be discussed in the local MDT11. Patients will be seen in the clinic to discuss histopathology results, any requirement for an additional procedure and subsequent radiotherapy and endocrine therapy discussed12. In order to obtain accurate follow-up information, patients will need to attend the hospital every year for mammograms for 5 years. Patients will be informed of the results of these as soon as possible after these have been carried out (usually within 2 weeks)13. The Trial Office will send Quality of Life questionnaires to complete at 6 months after surgery/VAE, and subsequently annually until year 514. The hospital research team provide follow-up information on patients for up to 5 years15. If there is enough tissue available, the trial will collect tissue samples from the diagnostic biopsy and from any future breast investigations or surgery, for research

InterventionsSurgery arm:- Standard surgical treatment as deemed appropriate by local MDT, including axillary sentinel lymph node biopsy- Adjuvant radiotherapy/endocrine therapy as per local treatment guidelinesVAE arm:- Image-guided vacuum excision of breast cancer- No axillary surgery- Adjuvant radiotherapy to breast- Adjuvant endocrine therapy

Sites will randomise patients into the trial using a bespoke electronic Remote Data Capture system, or via completion of a Randomisation Form followed by a telephone call the SMALL Trial Office. Patients will be randomised at a ratio of 1:2 in favour of the VAE arm using computerised minimisation technique




You can take part if:


Current inclusion criteria as of 02/06/2021:

1. Female aged ≥47 years old with screen-detected breast cancer
2. ≤15 mm maximum tumour diameter on mammogram and ultrasound
3. No associated malignant microcalcification outwith the mass lesion (calcification within the lesion is permitted)
4. Unifocal disease
5. Grade 1 disease on diagnostic core biopsy
6. ER strongly positive (Allred score of 7 or 8, or equivalent, e.g. at least moderate positivity in >66% of tumour cell nuclei)
7. PR strongly positive (Allred score of 7 or 8, or equivalent, e.g. at least moderate positivity in >66% of tumour cell nuclei)
8. HER2 negative (0 or 1+ by immunohistochemistry, or 2+ and negative by in situ hybridisation techniques (FISH or DISH)
9. Normal axillary ultrasound axillary, or equivocal ultrasound with benign fine needle aspiration cytology (FNAC) or core biopsy (CB)
10. Willing to be randomised
11. Able to provide written informed consent
12. Willing and able to undergo standard surgical treatment
13. Willing and able to undergo radiotherapy
14. Willing and able to take standard endocrine therapy
15. No previous diagnosis of ipsilateral breast cancer or DCIS (contralateral DCIS or invasive disease permitted if surgically treate


You may not be able to take part if:


Current exclusion criteria as of 02/06/2021:

1. Associated malignant microcalcification outwith the lesion2. Bilateral breast cancer3. Invasive lobular cancer4. Grade 2 or grade 3 on core biopsy assessment5. Not strongly ER or PR positive (Allred score of <7, or equivalent, e.g. <66% positivity of tumour cell nuclei) or HER2 positive tumour6. Unable to provide informed consent7. Any serious and/or unstable pre-existing medical, psychiatric or other condition that would prevent compliance with the trial or consent process8. Unfit or unwilling to undergo standard surgical treatment9. Contra-indications to standard adjuvant therapies (radiotherapy, endocrine therapy)10. Previous ipsilateral invasive breast cancer or DCIS11. Other invasive malignancy unless:- Disease free for 5 years, or-Previous basal cell carcinoma, cervical carcinoma in-situ, superficial bladder tumour12. High-risk group for developing breast cancer (as defined by NICE guidance)

_____

Previous exclusion criteria:

1. Lesions with associated mammographic microcalcification outwith the lesion2. Bilateral breast cancer3. Invasive lobular cancer4. Grade 2 or grade 3 on core biopsy assessment5. ER or PR negative or HER2 positive tumour6. Unable to provide informed consent7. Any serious and/or unstable pre-existing medical, psychiatric or other condition that would prevent compliance with the trial or consent process8. Unfit or unwilling to undergo standard surgical treatment9. Contra-indications to standard adjuvant therapies (radiotherapy, endocrine therapy)10. Previous ipsilateral invasive breast cancer or DCIS11. Other invasive malignancy treated within the last 5 years12. High-risk group for developing breast cancer (as defined by NICE guidance)


Below are the locations for where you can take part in the trial. Please note that not all sites may be open.

  • Churchill Hospital
    Churchill Hospital Old Road Headington
    Oxford
    OX3 7LE
  • Southmead Hospital
    Southmead Road Westbury-on-trym
    Bristol
    BS10 5NB
  • University College London Hospitals NHS Foundation Trust
    250 Euston Road
    London
    NW1 2PG
  • Leeds Teaching Hospitals NHS Trust
    St. James's University Hospital Beckett Street
    Leeds
    LS9 7TF
  • Aberdeen Royal Infirmary
    Foresterhill Road
    Aberdeen
    AB25 2ZN
  • The Royal Marsden Hospital (surrey)
    Downs Road
    Sutton
    SM2 5PT
  • Southampton General Hospital
    Tremona Road
    Southampton
    SO16 6YD
  • York Hospital
    Wigginton Road
    York
    YO31 8HE
  • Luton and Dunstable University Hospital
    Lewsey Road
    Luton
    LU4 0DZ
  • Western General Hospital
    Crewe Road South Edinburgh
    Lothian
    EH4 2XU
  • Forth Valley Royal Hospital
    Stirling Road
    Larbert
    FK5 4WR
  • Royal Bournemouth General Hospital
    Castle Lane East
    Bournemouth
    BH7 7DW
  • Worcestershire Royal Hospital
    Charles Hastings Way
    Worcester
    WR5 1DD
  • Castle Hill Hospital
    Castle Road
    Cottingham
    HU16 5JQ
  • Royal Devon and Exeter Hospital
    Barrack Road
    Exeter
    EX2 5DW
  • Liverpool University Hospitals NHS Foundation Trust
    Royal Liverpool University Hospital Prescot Street
    Liverpool
    L7 8XP
  • Kings College Hospital
    Mapother House De Crespigny Park Denmark Hill
    London
    SE5 8AB
  • University Hospital (coventry)
    Clifford Bridge Road
    Coventry
    CV2 2DX
  • Leighton Hospital
    Leighton
    Crewe
    CW1 4QJ
  • Cheltenham General Hospital
    Sandford Road
    Cheltenham
    GL53 7AN
  • Milton Keynes University Hospital
    Standing Way Eaglestone
    Milton Keynes
    MK6 5LD
  • Royal Cornwall Hospital (treliske)
    Treliske
    Truro
    TR1 3LJ
  • Poole Hospital
    Longfleet Road
    Poole
    BH15 2JB
  • Doncaster Royal Infirmary
    Armthorpe Road
    Doncaster
    DN2 5LT
  • Addenbrookes Hospital
    Hills Road
    Cambridge
    CB2 0QQ
  • Wythenshawe Hospital
    Southmoor Road Wythenshawe
    Manchester
    M23 9LT
  • Norfolk and Norwich University Hospital
    Colney Lane Colney
    Norwich
    NR4 7UY
  • Kingston Hospital
    Galsworthy Road
    Kingston upon Thames
    KT2 7QB
  • Ipswich Hospital
    Heath Road
    Ipswich
    IP4 5PD
  • Craigavon Area Hospital
    Lurgan Rd
    Craigavon
    BT63 5QQ
  • Altnagelvin Area Hospital
    Glenshane Road
    Londonderry
    BT47 6SB
  • Royal United Hospital
    Combe Park
    Bath
    BA1 3NG
  • Queen Elizabeth Hospital
    Edgbaston
    Birmingham
    B15 2TH
  • Bolton Royal Hospital
    Minerva Road Farnworth
    Bolton
    BL4 0JR
  • Alexandra Hospital
    Woodrow Drive
    Redditch
    B98 7UB
  • Macclesfield District General Hospital
    Macclesfield District Hospital Victoria Road
    Macclesfield
    SK10 3BL
  • The Royal Victoria Infirmary
    Queen Victoria Road
    Newcastle upon Tyne
    NE1 4LP
  • The Royal Marsden Hospital (london)
    Fulham Road
    London
    SW3 6JJ
  • Belfast City Hospital
    51 Lisburn Road
    Belfast
    BT8 8BH
  • Edgware Community Hospital
    Edgware Community Hospital Burnt Oak Broadway
    Edgware
    HA8 0AD
  • Thomas Linacre Centre
    Parson's Walk
    Wigan
    WN1 1RU
  • Gateshead - Queen Elizabeth Hospital
    Queen Elizabeth Hospital Sherriff Hill
    Gateshead
    NE9 6SX
  • Southend Hospital
    Prittlewell Chase
    Westcliff-on-sea
    SS0 0RY
  • North Tees General Hospital
    Hardwick Road
    Stockton-on-tees
    TS19 8PE
  • Wycombe General Hospital
    Queen Alexandra Road
    High Wycombe
    HP11 2TT
  • Gartnavel General Hospital
    1053 Great Western Road
    Glasgow
    G12 0YN
  • Cumberland Infirmary - Carlisle
    Cumberland Infirmary Newtown Road
    Carlisle
    CA2 7HY
  • Clatterbridge Hospital
    Clatterbridge Rd Bebington
    Wirral
    CH63 4JY

This information has not yet been provided by the study team. You'll have an opportunity to discuss any risks and benefits that may be associated with this study prior to consenting to taking part.


The study is sponsored by University of Birmingham and funded by NIHR Evaluation, Trials and Studies Co-ordinating Centre (NETSCC); Grant Codes: 17/42/32.




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Read full details for Trial ID: ISRCTN12240119

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Last updated 15 January 2025

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