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Increasing trend of contralateral prophylactic mastectomy: What are the factors behind this phenomenon?
Abstract
Introduction
Numerous studies have shown a trend towards increasing rates of contralateral prophylactic mastectomy (CPM) in the US. In this review, we will explore the trend, possible causative factors and outcomes from CPM.
Methods
We performed a literature review of all relevant retrospective reviews, clinical trials and review articles regarding contralateral prophylactic mastectomy.
Results
Several studies have noted a four to fivefold increase in CPM in recent years; an increase most notable in younger patients. When surveyed, patients report that the most important factors affecting their choice of CPM include fear of cancer recurrence, genetic counseling/testing, family history or additional high risk factors, stress surrounding close follow up, the availability of reconstructive surgery and information provided about contralateral breast cancer (CBC) risk and risk for local recurrence. Women who have undergone CPM do report high satisfaction with the procedure and some studies suggest risk reduction.
Conclusion
CPM rates have increased across the US and numerous factors have been reported to increase the likelihood of choosing CPM. Despite that bilateral mastectomy is associated with an increased risk of wound and overall postoperative complications for certain populations, this surgery appears to have psychological, cosmetic and possibly oncologic benefit.
... A record review of enrolled participants' histological results and demographic details was conducted at the Breast Care Clinic of Helen Joseph Hospital, a medium-sized public hospital in Johannesburg, South Africa. The patient details and chosen surgery (8)(9)(10)11,13,14) Invasive lobular (8,9,(11)(12)(13) Perceived benefit (16,17) High Socio-Economic Status (9,12,13) Small tumour size (<2 cm) (10) Influence by family/friends (17,18) Family History (7,10,13) Node negative (10) Over-estimation of risk (16,17,19) ER/PR negative (10) Radiation (10) First primary tumour (10) Neoadjuvant chemotherapy (12,15) BRCA 1/2 (12,13) information were captured prospectively in the Breast Care Clinic database at the time of diagnosis. ...
... A record review of enrolled participants' histological results and demographic details was conducted at the Breast Care Clinic of Helen Joseph Hospital, a medium-sized public hospital in Johannesburg, South Africa. The patient details and chosen surgery (8)(9)(10)11,13,14) Invasive lobular (8,9,(11)(12)(13) Perceived benefit (16,17) High Socio-Economic Status (9,12,13) Small tumour size (<2 cm) (10) Influence by family/friends (17,18) Family History (7,10,13) Node negative (10) Over-estimation of risk (16,17,19) ER/PR negative (10) Radiation (10) First primary tumour (10) Neoadjuvant chemotherapy (12,15) BRCA 1/2 (12,13) information were captured prospectively in the Breast Care Clinic database at the time of diagnosis. ...
... A record review of enrolled participants' histological results and demographic details was conducted at the Breast Care Clinic of Helen Joseph Hospital, a medium-sized public hospital in Johannesburg, South Africa. The patient details and chosen surgery (8)(9)(10)11,13,14) Invasive lobular (8,9,(11)(12)(13) Perceived benefit (16,17) High Socio-Economic Status (9,12,13) Small tumour size (<2 cm) (10) Influence by family/friends (17,18) Family History (7,10,13) Node negative (10) Over-estimation of risk (16,17,19) ER/PR negative (10) Radiation (10) First primary tumour (10) Neoadjuvant chemotherapy (12,15) BRCA 1/2 (12,13) information were captured prospectively in the Breast Care Clinic database at the time of diagnosis. ...
Background : International trends have shown that female patients with unilateral breast cancer are electing bilateral mastectomies as a prophylactic measure. The study aimed to determine the prevalence of unilateral mastectomies (UM) with and without contralateral prophylactic mastectomy (CPM) and to identify whether demographic and pathological characteristics predict the choice of CPM.
Methods : A record review of demographic details and pathological results of all female patients undergoing mastectomy for unilateral breast cancer from 2013-2015 was conducted at the Helen Joseph Breast Care Clinic in Johannesburg, South Africa.
Results : A total of 299 women who had mastectomies for unilateral breast cancer were included in the study. Of these, 59 had CPM (19.7%). Significantly more White women opted for a CPM than Black women (43.5% vs 10.6%, p♯αμπ;λτ;0.0001). Women who underwent CPM were significantly younger, and there was a trend for higher median breast weight than patients who only underwent UM (p = 0.03 and p = 0.09, respectively). There was no difference between the two groups with regard to patient income status, tumour histology, TNM stage or neoadjuvant chemotherapy.
Conclusion : The demographic and histopathological characteristics of breast cancer which influence the choice of CPM in the South African context have some similarities to those in the international literature in that White and younger women more often choose CPM compared to other racial groups. The more advanced stages of breast cancer presentation in our study suggest that public health awareness and screening measures need to be significantly strengthened in South Africa.
... Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we see a marked trend toward mastectomy in breast conserving surgery eligible patients [2]. Prophylactic mastectomy has also registered an upward trend [3,4]. This trend together with new indication for breast reconstruction like chest feminization in transgender patients [5] have increased the need for breast reconstruction surgery. ...
... The need to complete the surgical treatment of breast cancer with breast reconstruction derives from the beneficial impact at the psychological level, respectively at the level body image, of sexuality and general quality of life of patients [8]. In recent years the ever-increasing number of patients opting for prophylactic mastectomy due to genetic predisposition for developing breast cancer or family history of cancer [3,4,[9][10][11] has given birth to a new type of integrated treatment plan in oncology. ...
... Advances in oncological treatment, which have prolonged survivorship after breast cancer, also made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we see a marked trend toward mastectomy in breast conserving surgery (BCS) eligible patients [2]. Prophylactic mastectomy has also registered an upward trend [3,4]. This trend together with new indication for breast reconstruction like chest feminization in transgender patients [5,12,14] or the need to resolve the asymmetry of the contralateral breast [15][16][17], have increased the need for breast reconstruction surgery. ...
(1) Importance of problem: Breast cancer accounted for 685.000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor beside gender and age-group. During last 4 decades we see a reduction by 40% of age-standardized breast cancer [1], which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we see a marked trend toward mastectomy in breast conserving surgery eligible patients [2]. Prophylactic mastectomy has also registered an upward trend [3,4]. This trend together with new indication for breast reconstruction like chest feminization in transgender patients [5] have increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results and the safety profiles when used during the integrated treatment plan of the oncologic patient; (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures, summarized the findings and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.
... Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients [2]. Prophylactic mastectomies have also registered an upward trend [3,4]. This trend together with new uses for breast reconstruction like chest feminization in transgender patients [5] has increased the need for breast reconstruction surgery. ...
... The need to complete the surgical treatment of breast cancer with breast reconstruction derives from the beneficial impact at the psychological level, respectively, for the body image, sexuality, and general quality of life of patients [10]. In recent years, the everincreasing number of patients opting for prophylactic mastectomies due to a genetic predisposition for developing breast cancer or a family history of cancer [3,4,[11][12][13] has given birth to a new type of integrated treatment plan in oncology. Changes in guidelines, prompting the genetic testing of BRCA mutations and the availability of those tests even in the absence of an oncologist's recommendation, have determined an increase in the number of women getting tested and then opting for a contralateral or bilateral prophylactic mastectomy. ...
... Advances in oncological treatment, which have prolonged patients' survivorship after breast cancer, have also made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomy in breast-conserving surgery (BCS)-eligible patients [2]. Prophylactic mastectomy has also registered an upward trend [3,4]. This trend, together with new indications for breast reconstruction like chest feminization in transgender patients [5,14,16] or the need to resolve the asymmetry of the contralateral breast [17][18][19], have increased the need for breast reconstruction surgery. ...
(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the “gold standard”, but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.
... Contralateral BC risks are influenced by multiple factors, including age at first BC diagnosis, family history of BC, previous treatments, and underlying genetic predisposition [4,[18][19][20][21][22]. The risk for a contralateral BC is approximately 10% within 20 years after the initial diagnosis for unselected women with no known hereditary BC predispositions, [22] but may be as high as 53-65% for BRCA1/2 PV/LPV carriers [4,23]. Contralateral BC risks have not been well-defined for most other BC predisposition genes, but may be increased for women with ATM, PALB2, TP53, and CHEK2 truncating PV/LPVs [13,[24][25][26][27]. ...
... Similar to previous studies [23,[36][37][38][60][61][62], our data showed that a family history of BC diagnosed at age 40 or younger and/or OC was associated with a decision to have CRRM. Thus, although comprehensive GT could identify patients with increased risk for a second primary breast cancer, young patients diagnosed with BC might choose to have CRRM based on their perception of a high risk for contralateral BC in the presence of a significant family history [63]. ...
... Higher CRRM rates with early stage disease have previously been reported [23,37,61], however, disease stage was not shown to be associated with CRRM in our study. Approximately a third of the patients had stages 0 or I at the time of diagnosis. ...
Purpose
Genetic testing (GT) can identify individuals with pathogenic/likely pathogenic variants (PV/LPVs) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic.
Methods
Clinical data were reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤ 45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated.
Results
Of the 194 patients, 30 (15.5%) had a PV/LPV in a BC predisposition gene (ATM, BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV/LPV carriers and 42/164 (25.6%) non-carriers. A positive test result (p < 0.01) and significant family history were associated with CRRM (p = 0.02). For the 164 with uninformative results, multivariate analysis showed that CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.10), or BC stage (p = 0.11).
Conclusion
In this cohort of young women with BC, the identification of a PV/LPV in a BC predisposition gene and a significant family history were associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.
... [4,[14][15][16][17][18] The risk for a contralateral BC is approximately 10% within 20 years after the initial diagnosis for unselected women with no known hereditary BC predispositions, [18] but may be as high as 53-65% for BRCA1/2 PV carriers. [4,19] Contralateral BC risks have not been well-defined for most other BC predisposition genes, but may be increased for women with ATM, PALB2, TP53, and CHEK2 truncating PVs. [13,[20][21][22][23] Genetic testing (GT) is recommended for women with newly diagnosed BCs who meet specific criteria based on their personal and family cancer history, as the identification of a hereditary predisposition may impact care. ...
... [14][15][16][17][18] Consequently, earlier age at diagnosis and family history of BC/OC have been shown to be positively correlated with the decision to have CRRM in women with BC, regardless of genetic testing outcome. [19,37,38,46,[60][61][62] In this study, we did not observe any association between age at diagnosis and surgical decision when adjusted for GT result. However, all patients included in this study were 45 years old or younger, which hindered the ability to evaluate the impact of age at diagnosis on surgical decision making. ...
... Previous studies showing an association between family history of BC/OC and CRRM in women with BC either did not include information on GT, or only considered test results for BRCA1/2. [19,36,37,60,[63][64][65] In our study, comprehensive GT could have identified patients with a BC predisposition who otherwise would have chosen CRRM based on family history. Furthermore, patients diagnosed with BC might choose to have CRRM based on their perception of a high risk for contralateral BC, especially when there is a significant family history. ...
PURPOSE: Genetic testing (GT) can identify individuals with pathogenic variants (PV) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic.
METHODS: Clinical data was reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated.
RESULTS: Of the 194 patients, 30 (15.5%) had a PV in a BC predisposition gene (ATM , BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV carriers and 42/164 (25.6%) non-carriers. Only a positive test result was associated with CRRM (p < 0.01). For the 164 with uninformative results, CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.19), or BC stage (p = 0.10).
CONCLUSION: In this cohort of young women with BC, the identification of a PV in a BC predisposition gene was the only factor associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.
... [1][2][3] This may be attributed to a multitude of factors including fear of developing another breast cancer, the use of highly sensitive diagnostic modalities such as magnetic resonance imaging, improved diagnosis of hereditary breast cancer as in patients with BRCA mutations, and improved access to breast reconstruction. 1,2,[4][5][6][7][8][9][10][11][12] However, bilateral mastectomy is an extensive surgical procedure which often results in longer inpatient hospital stays, higher transfusion rates, and increased reoperation rates. [13][14][15] The risks traditionally associated with unilateral breast reconstruction may be compounded in patients undergoing bilateral reconstruction. ...
... The decision to undergo bilateral mastectomy is likely multifactorial and strong associations have been shown with patient age, race, and even reconstruction status. 2 Patients may choose to undergo bilateral mastectomy due to anxiety and perceptions regarding risk of contralateral breast cancer. 11 In addition, patients may believe that bilateral mastectomy will improve reconstruction outcomes. 11 Recently, a survey study found that breast surgeons remain uncomfortable with bilateral ...
... 11 In addition, patients may believe that bilateral mastectomy will improve reconstruction outcomes. 11 Recently, a survey study found that breast surgeons remain uncomfortable with bilateral ...
Background
Utilization of bilateral mastectomy for unilateral breast cancer is increasing despite cost and surgical risks with conflicting reports of survival benefit. Current studies evaluating death after bilateral mastectomy have included patients treated both with breast conservation therapy and unilateral mastectomy. In this study, we directly compared breast cancer–specific death of patients who underwent bilateral or unilateral mastectomy for unilateral breast cancer using a matched cohort analysis.
Methods
This was an observational study of women diagnosed with unilateral breast cancer from 1998 through 2002, using the Surveillance, Epidemiology, and End Results (SEER) database. A 4-to-1 matched cohort of patients was selected including 14,075 patients. Mortality of the groups was compared using Cox proportional hazards models for cause-specific death.
Results
A total of 41,510 patients diagnosed with unilateral breast cancer were included. Unilateral mastectomy was performed in 93% of patients, while bilateral mastectomy was performed in the remaining 7% of patients. When 4-to-1 matching was performed, 11,260 unilateral mastectomy and 2,815 bilateral mastectomy patients were included. Patients with bilateral mastectomy did not have a significantly lower hazard of breast cancer–specific death when compared with patients with unilateral mastectomy (hazard ratio: 0.92 vs 1.00, p=0.11).
Conclusion
Bilateral mastectomy did not provide a clinically or statistically significant breast cancer–specific mortality benefit over unilateral mastectomy based on a matched cohort analysis of a nationwide population database. These findings should be interpreted in the context of patient preference and alternative benefits of bilateral mastectomy.
... Women diagnosed with unilateral breast cancer (BC) are increasingly undergoing contralateral prophylactic mastectomy (CPM) worldwide [1,2]. Amongst 1.1 million American BC patients, CPM rates rose from 2.0% to 12.3% from 1998 to 2011 [3]. ...
... Research has explored clinical, demographic and psychological predictors of CPM uptake, including overestimated perceptions of CBC risk and CPM's survival benefit [16], avoidance of future breast surveillance [2,16], and desire for breast symmetry after unilateral mastectomy [17]. Social-cognitive and emotional factors identified as influential in CPM decision-making include women's expectations of positive or negative CPM outcomes, avoiding uncertainty and regret, reducing recurrence-related anxiety, and social norms [17e19]. ...
... Risk-reduction also appeared to be one of numerous factors determining the magnitude of benefit required. For example, reducing worry and fear, breast symmetry, circumventing other risk-management strategies and future treatment were other important factors, consistent with literature that cosmetic appearance [16], surveillance difficulties [23] and avoiding preventative strategies [2] motivate CPM decision-making. Minimising discomfort while screening, while communicating the efficacy of screening in detecting CBCs while at an early and potentially curable stage [9], would appear important. ...
Objectives:
Contralateral prophylactic mastectomy (CPM) reduces the risk of contralateral breast cancer (BC) following unilateral BC, but may not increase survival in BRCA1/2 mutation negative women. Despite this, and the risk for adverse physical and psychological impact, uptake is increasing in BRCA1/2 mutation negative women. We aimed to quantify the degree of reduction in lifetime contralateral BC risk women required to justify CPM, and to explore demographic, disease and psychosocial predictors of preferences using Protection Motivation Theory (PMT) as a theoretical framework. Reasoning behind preferences was also examined.
Materials and methods:
388 women previously diagnosed with unilateral BC, of negative or unknown BRCA1/2 status, were recruited from an advocacy group research database. Two hypothetical risk trade-off scenarios were used to quantify the reduction in lifetime contralateral BC risk that women judged necessary to justify CPM, using a 5% and 20% baseline. Demographic, disease and PMT measures were assessed using a questionnaire.
Results:
Most women required their risk to be more than halved from a 5% or 20% baseline to justify CPM. Polarised preferences were also common, with some women consistently accepting or refusing CPM independent of risk/benefit trade-offs. Preferences were associated with coping self-efficacy and having a prior CPM. Explanations for judging CPM worthwhile included reducing or eliminating contralateral BC risk, attaining breast symmetry and reducing worry.
Conclusion:
Risk-reduction preferences were highly variable. Decisive factors in women's preferences for CPM related to clinical, psychological and cosmetic outcomes, but not to demographic or disease characteristics.
... As a preventive option CPM is chosen mostly by women with history of previous breast cancer, especially if they are BRCA ½ mutation carriers or have family history of BC [1,10,11] Factors for the increase of CPM Increased frequency of CPM is explained by multiple factors and is directly connected with several features of the patient, the primary tumor, as well as some particularities of the contemporary diagnostic and treatment process. ...
... (A) On behalf of the patients [2,5,10,[12][13][14][15][16]: young age (less than 50 y.o.); white race; family history; highly educated women; higher socio-economic status; additional (private) health insurance; patients with depression; previous breast biopsy with high risk lesions (atypical hyperplasia, LCIS); desire (will) of the patient. ...
... (B) On behalf of the primary tumor [6,10,12,[17][18] of critical importance are Lobular carcinoma (in 30% of cases involves the contralateral breast); multicentric cancer; ER (-) tumor; triple negative primary cancer; previous radiotherapy. ...
The contemporary tendency for increase of prophylactic surgical procedures as part of the sophisticated treatment of breast cancer is the foundation for the present study. Evaluation of risk factors for developing contralateral breast cancer, factors for an increase in prophylactic mastectomies and indications for performing those operations are briefly commented. Analysis of 12 cases of the authors surgical practice is presented regarding treatment approach from the oncological, reconstructive and aesthetic point of view. Results, complications, alternative methods, clinical importance and possible future aspects are discussed.
... Patients with unilateral diagnosis of breast cancer increasingly elect to undergo bilateral mastectomies. [1][2][3][4][5][6][7] Even though the risk of contralateral breast cancer is low in the absence of a genetic mutation, patient misperceptions of the true benefits of a contralateral prophylactic mastectomy might account for this increase. 1 , 8 , 9 Young patient age, Caucasian ethnicity, higher education level, family history, and positive genetic testing have been shown to be predictors of prophylactic surgery. ...
... The rate of contralateral prophylactic mastectomy has more than doubled in the past decades, with a similar trend in immediate reconstruction. [1][2][3][4][5][6][7] Patients with no proven genetic predisposition also opt for this elective operation likely due to cancer-related anxiety, despite the lack of evidence for a survival benefit. 1 , 8 , 11 , 21-23 The availability of reconstruction appears to influence patient decision-making 6 , 7 , 12 , 15 , 24 , 25 , and there is evidence of higher patient satisfaction and superior long-term cosmetic outcome with bilateral implantbased reconstruction. 17 , 18 , 26-28 Although it may seem intuitive to surgeons that bilateral surgery is associated with higher complication rates when compared with unilateral surgery, patients do not necessarily perceive added risk. ...
Introduction:
Contralateral prophylactic mastectomy has the potential to decrease the occurrence of cancer and reduce psychological burden. However, it is known that complications after bilateral mastectomy are higher compared with unilateral mastectomy. Our goal was to evaluate outcomes of immediate breast reconstruction in patients undergoing bilateral mastectomy and to compare complication rates between therapeutic and prophylactic sides.
Patients and methods:
Electronic medical records of patients with unilateral breast cancer who underwent bilateral mastectomy and immediate reconstruction with expanders were reviewed. Postoperative complications were compared between therapeutic and prophylactic mastectomy sides.
Results:
Sixty-two patients were analyzed. The overall complication rate after both stages was 23.9% on the therapeutic side and 16.5% on the prophylactic side. Infection was the most common complication on both sides. All infections on the prophylactic mastectomy side were successfully treated with intravenous (IV) antibiotics (salvage rate of 100%), whereas 35.7% of infected tissue expander/implants on the therapeutic mastectomy side were explanted despite treatment.
Conclusion:
Careful counselling of patients undergoing elective contralateral prophylactic mastectomy is essential as complications can develop in either breast after reconstruction.
... However, other retrospective studies with longer follow-up have shown that BM patients report higher breast satisfaction and psychosocial well-being [14] or higher satisfaction alone [15] than UM patients. Despite these differences in outcomes, women in all treatment groups tend to report high rates of decisional satisfaction [5,14,[16][17][18][19][20][21][22]. ...
... In order to assess the influence of surgery choice on cancer worry, the Fear of Relapse/Recurrence Scale (FRRS) was given at all postoperative time points. The FRRS is a 5-item measure to determine patients' beliefs and anxiety about their cancer recurring [20,29]. Each item is rated on a 5-point Likert scale with higher scores reflecting a greater fear of recurrence. ...
Purpose:
More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer.
Methods:
We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15 months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal-Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point.
Results:
203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15 months, it was significantly lower in BM patients than in BCT patients. Women who felt "very" confident and "very" informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15 months.
Conclusion:
While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.
... [9][10][11][12][13] Despite these findings, rates of CPM continue to increase. 12,13,[21][22][23][24][25] Although the reasons for this trend are under investigation, 2,5,7,21,22,26-28 patient anxiety and overestimation of personal contralateral breast cancer risk (CBC) have received substantial attention as a driving force for the increasing utilization of CPM. 4,15,21,24,27,29 Using patient-directed surveys, one previous study has shown that patients overestimate their risk for CBC, with 10-year self-reported risk estimates over 30%. ...
... 12,13,[21][22][23][24][25] Although the reasons for this trend are under investigation, 2,5,7,21,22,26-28 patient anxiety and overestimation of personal contralateral breast cancer risk (CBC) have received substantial attention as a driving force for the increasing utilization of CPM. 4,15,21,24,27,29 Using patient-directed surveys, one previous study has shown that patients overestimate their risk for CBC, with 10-year self-reported risk estimates over 30%. 29 However, these self-reported risk assessments contrast sharply with several population-based studies-Reiner et al reported the 10-year cumulative risk of contralateral breast cancer (CBC) to range from 4.0% to 7.0% among patients with no family history of breast cancer or BRCA1/2 mutation. ...
Background:
An increasing number of patients undergo contralateral prophylactic mastectomy (CPM) for unilateral breast cancer. However, the benefit of CPM has not been quantified in the setting of contemporary breast cancer therapy.
Methods:
We performed an analysis of 180 068 patients in the Surveillance, Epidemiology, and End Results (SEER) database, diagnosed with unilateral ductal breast carcinoma between 1998 and 2013 and treated with unilateral mastectomy (UM) or CPM. UM was performed in 146 213 patients (81.2%); CPM was performed in 33 855 patients (19.8%). Primary outcome of interest was cumulative incidence of a second primary breast cancer in the ipsilateral or contralateral breast greater than 3 months after initial diagnosis. Cumulative incidence analysis was based on a Cox proportional model to generate curves of second primary breast cancer in any breast, ipsilateral breast only, or contralateral breast only.
Results:
Patients who underwent CPM had a significantly reduced incidence of second primary breast cancer 10 and 15 years after surgery (CPM 0.93% [0.73%, 1.12%] vs UM 4.44% [4.28%, 4.60%]). Patients who underwent CPM had significantly lower adjusted hazard of second primary breast cancer when compared with UM (HR 0.38 vs 1.0, P < .0001).
Conclusions:
CPM offers some protection from a second primary breast cancer, attributable to a reduced incidence in the contralateral breast. These findings provide additional information to providers and patients as they make decisions regarding surgical management. They should also be interpreted in the context of the absolute incidence of second primary breast cancer after UM and previous literature demonstrating no survival benefit.
... Over the last several decades there has been a steady increase in the choice for CPM by these patients and there is no sign of this trend reversing (1,2). This trend is amplified in women undergoing mastectomy with immediate breast reconstruction (IBR) (3)(4)(5). ...
... It seems that the discussion with patients swings from breast conservation to bilateral mastectomy, with unilateral mastectomy glossed over as an option by many women. The impact of the increased availability and increased use of breast reconstruction on the rates of CPM have been documented in multiple studies (3)(4)(5). This was also seen in the current study as women who reported CPM were more likely to have had reconstruction than women without CPM (OR, 1.72). ...
... In Canada, lower CPM rates have been noted on a national level compared to the United States [10] , but these rates were obtained through administrative databases and no patient level, surgical procedure detail, or outcomes data were reported [10] . Since CPM rates are known to be influenced by resource factors, such as access to genetic testing and immediate breast reconstruction, and other patient factors such as age [1][2][3]7,8,[11][12][13][14] , examining CPM trends with patient and procedure level data will provide more detailed information on the CPM landscape in Canada. Therefore, our main objective was to examine the rates and trends of immediate CPM and to compare outcomes of patients undergoing CPM to patients having unilateral mastectomy (UM) alone at a Canadian academic breast cancer center. ...
... Interestingly, the factors associated with increased rates of immediate CPM at our institution are similar to those found in the United States literature -suggesting that the patient factors influencing the decision to undergo a CPM are possibly the same between the two countries. Within our population, younger patients and those with family history were more likely to undergo CPM, similar to patients in the numerous United States studies [1][2][3]7,8,[12][13][14] . Furthermore, the use of immediate reconstruction has been associated with increased CPM rates [11,13] , and our study results support this finding. ...
Aim:
To examine trends of contralateral prophylactic mastectomy (CPM) rates at a Canadian academic breast cancer center.
Methods:
A single-institution retrospective cohort study was completed. Women of any age who underwent at least a unilateral mastectomy (UM) for primary unilateral breast carcinoma between January 1, 2004 and December 31, 2010 were included. Patients who underwent CPM on the same day as UM were isolated to create two distinct cohorts. Patient and procedure characteristics were compared across groups using R software (version 3.1.0). The percentage of CPMs per year was determined. The Cochrane-Armitage test was used to assess the trend of CPMs over time. A P value of < 0.05 was considered significant.
Results:
A total of 811 women met the inclusions/exclusion criteria; 759 (93.6%) underwent UM alone and 52 (6.4%) underwent UM with immediate CPM. The absolute number of procedures (UM and UM + CPM) increased over time, from 83 in 2004 to 147 in 2010 reflecting an increase in mastectomy volume. Annual CPM rates did not increase over time (P = 0.7) and varied between 2.6% to 10.7%. Family history of breast cancer [OR 3.6 (1.8-7.3)] and immediate reconstruction [10.0 (5.2-19.3)] were both significantly associated with CPM. Women who underwent CPM were younger (median age CPM 49 years vs UM 52 years, P < 0.0001) but age less than 50 years was not statistically associated with increased rates of CPM.
Conclusion:
CPM rates from 2004 to 2010 at a high-volume Canadian breast cancer center did not increase over time, in contrast to trends observed in the United States.
... In addition, rates of CPM are also on the rise for both invasive and in situ cancer (1,6,7). There are several reasons for these phenomena, including the increasing use of preoperative MRI, the growing employment of immediate post-mastectomy reconstruction, improvements in cosmetic results with the relatively new techniques of skin-and nipple-sparing mastectomy, the increasing use of genetic testing, and last but not least, the patients' entitlement to choose their preferred surgery option (6)(7)(8)(9)(10)(11)(12). ...
... In fact, novel techniques or approaches in surgical oncology should be directed towards survival benefits rather than a simple risk reduction. It is important to highlight that no studies in the literature have demonstrated an advantage in terms of survival by performing a contralateral mastectomy in patients with unilateral breast cancer, except (probably) in the scenario of germline mutations in breast-cancer susceptibility genes (1,2,6,15). ...
Rates of mastectomy and contralateral prophylactic mastectomy (CPM) are increasing in patients with unilateral breast cancer who would be candidates for receiving breast-conserving surgery, according to recent studies. One reason for this finding is the entitlement of patients to choose to undergo a bilateral mastectomy as a surgery option. The present case report details the case of a 52-year-old woman, eligible for breast conservation, who had no high risk of developing a contralateral breast cancer, but who asked for a bilateral mastectomy and immediate reconstruction instead of breast-conserving surgery. The request for a bilateral mastectomy was declined on the basis that it would be unnecessary for the patient, and an excessive intervention; the patient subsequently obtained an independent second opinion, and she underwent a bilateral mastectomy with implant reconstruction prior to receiving wound care and follow-up at our institution. At follow-up 1 year later, the patient complained of sensations of general discomfort, sexual difficulties and a loss of sensation in the nipples. On the basis of the clinical outcomes of the bilateral mastectomy and the patient's experience of the operation, the present case study highlights a need for surgeons to clearly inform patients presenting with unilateral breast cancer about the attendant risks and real benefits of bilateral mastectomy, in order to reach a mutual decision in terms of health care that is not fuelled by anxiety or an overestimation of the risk of developing secondary cancer. Bilateral mastectomy should be attentively evaluated as an option only in patients with a higher-than-average risk of developing contralateral breast cancer.
... Patients' perceptions of cancer and their emotional experiences influence BC treatment decision-making. Fear of cancer recurrence is among the most important factors in BLM choice [22,23]. In a sample of 550 women diagnosed with unilateral BC who elected BLM, the top reasons were to reduce the risk of cancer, enhance peace of mind, and improve survival/extend life [24]. ...
Background
Despite bilateral mastectomy (BLM) for early‐stage breast cancer (BC) showing no survival benefit and increased risk compared to breast conserving surgery, some patients still choose this treatment. This study examined whether emotion reactivity and regulation influence treatment decision making among newly diagnosed women with breast cancer.
Methods
Cross‐sectional survey data were analyzed as part of a larger study. Measures included the Contralateral Prophylactic Mastectomy (CPM) survey, PROMIS Anxiety scale, and Emotion Regulation Questionnaire (ERQ) Cognitive Reappraisal and Emotional Suppression subscales. Primary analysis included a logistic regression model predicting treatment choice (BLM vs. non‐BLM).
Results
Participants (N = 137) with unilateral BC (Stages 0–III) were divided between BLM (n = 66) versus breast conserving surgery (i.e., non‐BLM, n = 71) treatment groups. Compared to the non‐BLM group, the BLM group was younger, more likely to be partnered, and had a higher household income. Women with high levels of BC‐specific worry were 3.6 times more likely to choose BLM compared to women with low levels of worry (OR = 3.09, 95% CI: 1.07–0.8.93). Those who used cognitive reappraisal were 10% less likely to choose BLM compared to women who did not use cognitive reappraisal (OR = 0.90, 95% CI: 0.82–0.99). There were no group differences in levels of generalized anxiety (OR = 0.93, 95% CI: 0.87–0.99) or emotional suppression (OR = 1.02, 95% CI: 0.90–1.16).
Conclusions
Findings suggest the choice of BLM may be due, in part, to negative emotional experiences after a BC diagnosis and lesser use of reappraisal to reframe cancer‐related fears. These may be important targets of intervention to support women making BC treatment decisions.
... But research has also repeatedly shown high satisfaction rates for women who choose CPM. 1,4,[33][34][35][36] Indeed, it would seem that despite clear and concerted efforts from within the surgical establishment to discourage the use of CPM for "averagerisk" women with unilateral cancer, many of these women continue to ask for, receive, and be satisfied with this treatment choice. Given the persistence of this trend, we must consider the possibility that continued arguments against CPM are based, at least in part, on an assumption that patients are simply wrong in their preference for and satisfaction with this treatment, that they are failing to "choose wisely," as recent campaigns against surgical overtreatment have put it. ...
Contralateral prophylactic mastectomy is the removal of both breasts when only one is affected by cancer. Rates of this controversial cancer treatment have been increasing since the late 1990s, even among women who do not have the kind of family history or known genetic mutation that would put them at high-risk for another breast cancer. Citing contralateral prophylactic mastectomy’s lack of oncologic benefit and increased risk of surgical complications, the American Society of Breast Surgeons discourages contralateral prophylactic mastectomy for average-risk women with unilateral cancer, as does most of the medical literature on this topic. Within this literature, desire for contralateral prophylactic mastectomy is often painted as the product of an emotional overreaction to a cancer diagnosis and misunderstanding of breast cancer risk. Drawing on the personal experience of a breast cancer survivor, as well as relevant medical literature on breast cancer screening and surgery, this article offers a different perspective on the ongoing popularity of contralateral prophylactic mastectomy, one that focuses on practical experiences and logical deliberations about those experiences. Specifically, it calls attention to two features of the contralateral prophylactic mastectomy decision-making situation that have been inadequately covered in the medical literature: (1) the way that breast cancer screening after a breast cancer diagnosis can become a kind of radiological overtreatment, even for “average-risk” women; and (2) how desire for bodily symmetry after breast cancer, which can best be achieved through bilateral reconstruction or no reconstruction, drives interest in contralateral prophylactic mastectomy. The goal of this article is not to suggest that all women who want contralateral prophylactic mastectomy should have the surgery. In some cases, it is not advisable. But many “average-risk” women with unilateral cancer have good reasons for wanting contralateral prophylactic mastectomy, and we believe their right to choose it should be protected.
... Furthermore, extensive studies have demonstrated that prophylactic bilateral surgery not only fails to prolong the survival of BC patients, but also causes more complications than unilateral mastectomy (ULM). [9][10][11] There is, therefore, an urgent need for individualized predictive models of CBC risk to enable surgeons and women themselves to decide on prevention and treatment strategies, and to avoid over-screening and treatment when CBC risk is low. ...
The main purpose of this study was to build a prediction model for patients with contralateral breast cancer (CBC) using competing risks methodology. The aim is to help clinicians predict the probability of CBC in breast cancer (BC) survivors.
We reviewed data from the Surveillance, Epidemiology, and End Results database of 434,065 patients with BC. Eligible patients were used to quantify the association between the development of CBC and multiple characteristics of BC patients using competing risk models. A nomogram was also created to facilitate clinical visualization and analysis. Finally, the stability of the model was verified using concordance index and calibration plots, and decision curve analysis was used to evaluate the clinical utility of the model by calculating the net benefit.
Four hundred thirty-four thousand sixty-five patients were identified, of whom 6944 (1.6%) developed CBC in the 10 years follow-up. The 10-year cumulative risk of developing CBC was 2.69%. According to a multivariate competing risk model, older patients with invasive lobular carcinoma who had undergone unilateral BC surgery, and whose tumor was better differentiated, of smaller size and ER-negative/PR-positive, had a higher risk of CBC. The calibration plots illustrated an acceptable correlation between the prediction by nomogram and actual observation, as the calibration curve was closed to the 45° diagonal line. The concordance index for the nomogram was 0.65, which indicated it was well calibrated for individual risk of CBC. Decision curve analysis produced a wide range of risk thresholds under which the model we built would yield a net benefit.
BC survivors remain at high risk of developing CBC. Patients with CBC have a worse clinical prognosis compared to those with unilateral BC. We built a predictive model for the risk of developing CBC based on a large data cohort to help clinicians identify patients at high risk, which can then help them plan individualized surveillance and treatment.
... Because the goal of many CPM studies is to discourage this choice, researchers sometimes present high satisfaction rates in misleading or odd ways, for instance by highlighting the relatively small percent of women who report dissatisfaction with the procedure (e.g., Boughey et al. 2016b) or by attaching data about the high rate of satisfaction to a subordinating conjunction like "although" (e.g., Kurian et al. 2014). Despite the way information about CPM satisfaction is presented, though, the consensus is clear, with most studies showing about 80-90% satisfaction with the procedure (Tuttle et al. 2007;Soran et al. 2014;Kurian et al. 2014;Ager et al. 2016;Boughey et al. 2016b;Benson and Winters 2016;Hwang et al. 2016;and Anderson et al. 2017). ...
Since the late 1990s, the use of contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer has been on the rise. Over the past two decades, dozens of studies have been conducted in order to understand this trend, which has puzzled and frustrated physicians who find it at odds with efforts to curb the surgical overtreatment of breast cancer, as well as with evidence-based medicine, which has established that the procedure has little oncologic benefit for most patients. Based on the work of Annemarie Mol and John Law, this paper argues that these efforts to understand increased CPM use are limited by the “epistemology problem” in medicine, or, in other words, the tendency to view healthcare controversies and decision making exclusively through the lenses of objective and subjective forms of knowledge. Drawing on public discourse about rationales for choosing CPM, we argue that this surgical trend cannot adequately be understood in terms of what doctors and patients know about breast cancer risk and how CPM affects that risk. In addition, it must be recognized as the outcome of how specific practices of screening, detection, and treatment do or enact the bodies of patients, producing tensions in their lives that cannot be remedied with better or better communicated information. Recognizing the embodied realities of these enactments and their effects on patient decision making, we maintain, is essential for physicians who want to avoid the paternalism that haunts breast cancer treatment in the US.
... Discussing CPM with a surgeon at the time of diagnosis (i.e., prior to the baseline survey) was the strongest predictor of subsequent CPM receipt. Surgeon's recommendation has consistently emerged as a key predictor of CPM [19,37] including a recent retrospective study of patients with a negative test result [24]. We distinguished between discussion of CPM and CPM recommendation. ...
Purpose:
Recent trends indicate increased use of contralateral prophylactic mastectomy (CPM) among newly diagnosed breast cancer patients, particularly those who test positive for a pathogenic variant in the BRCA1/2 genes. However, the rate of CPM among patients who test negative or choose not to be tested is surprisingly high. We aimed to identify patient predictors of CPM following breast cancer diagnosis among such patients.
Methods:
As part of a randomized controlled trial of rapid genetic counseling and testing vs. usual care, breast cancer patients completed a baseline survey within 6 weeks of diagnosis and before definitive surgery. Analyses focused on patients who opted against testing (n = 136) or who received negative BRCA1/2 test results (n = 149). We used multivariable logistic regression to assess the associations between sociodemographic, clinical- and patient-reported factors with use of CPM.
Results:
Among patients who were untested or who received negative test results, having discussed CPM with one's surgeon at the time of diagnosis predicted subsequent CPM. Patients who were not candidates for breast-conserving surgery and those with higher levels of cancer-specific intrusive thoughts were also more likely to obtain a CPM.
Conclusion:
The strongest predictors of CPM in this population were objective clinical factors and discussion with providers. However, baseline psychosocial factors were also independently related to the receipt of CPM. Thus, although CPM decisions are largely guided by relevant clinical factors, it is important to attend to psychosocial factors when counseling newly diagnosed breast cancer patients about treatment options.
... Women in our study, whether they underwent cpm or not, believed that bilateral mastectomy would improve reconstruction outcomes 34 . One way to address fear, anxiety, and esthetic concerns on the part of patients is to develop educational materials such as patient decision aids that accurately inform patients about the risks of contralateral bca and of future recurrence, the lack of a survival benefit for cpm, the psychosocial ramifications of cpm, and the outcomes of reconstruction, including its risks and benefits 35 . ...
Background:
Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca.
Methods:
This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs.
Results:
In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%).
Conclusions:
Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.
... Evidence has suggested that women overestimate the survival advantage associated with CPM, 16 which highlights the importance of presurgical education and counselling. To effectively counsel women who are considering CPM, it is important to understand what factors predict its uptake. ...
Background
The rates of contralateral prophylactic mastectomy (CPM) are increasing in women with breast cancer. Previous retrospective research has examined clinical and demographic predictors of the uptake of CPM. However, to the authors' knowledge, there has been very little prospective research to date that has examined psychosocial functioning prior to breast cancer surgery to determine whether psychosocial functioning predicts uptake of CPM. The current study was conducted to evaluate demographic, clinical, and psychosocial predictors of the uptake of CPM in women with unilateral breast cancer without a BRCA1 or BRCA2 mutation.
Methods
Women with unilateral non–BRCA‐associated breast cancer completed questionnaires prior to undergoing breast cancer surgery. Participants completed demographic and psychosocial questionnaires assessing anxiety, depression, cancer‐related distress, optimism/pessimism, breast satisfaction, and quality of life. Pathological and surgical data were collected from medical charts.
Results
A total of 506 women consented to participate, 112 of whom (22.1%) elected to undergo CPM. Age was found to be a significant predictor of CPM, with younger women found to be significantly more likely to undergo CPM compared with older women (P < .0001). The rate of CPM was significantly higher in women with noninvasive breast cancer compared with those with invasive breast cancer (P < .0001). Women who elected to undergo CPM had lower levels of presurgical breast satisfaction (P = .01) and optimism (P = .05) compared with women who did not undergo CPM.
Conclusions
Psychosocial functioning at the time of breast cancer surgery decision making impacts decisions related to CPM. Women who have lower levels of breast satisfaction (body image) and optimism are more likely to elect to undergo CPM. It is important for health care providers to take psychosocial functioning into consideration when discussing surgical options.
... More women with early-stage, unilateral breast cancer and low genetic risk are choosing contralateral prophylactic mastectomy (CPM). [1][2][3][4][5][6][7][8][9][10][11] This trend is increasing, despite evidence that the risk for developing cancer in the healthy breast is low [2][3][4][5] and that removing the unaffected breast does not confer a survival advantage or quality of life benefit. 2 ...
Objective
Women with unilateral, early‐stage breast cancer and low genetic risk are increasingly opting for contralateral prophylactic mastectomy (CPM), a concerning trend because CPM offers few clinical benefits while increasing risks of surgical complications. Few qualitative studies have analyzed factors motivating this irreversible decision. Using qualitative methods this study sought to understand women's decision‐making and the impact of CPM on self‐confidence, sense of femininity, sexual intimacy and peace of mind.
Methods
Women who had CPM within the last 10 years were recruited to participate in the study. We conducted a thematic analysis of the data.
Results
45 women were interviewed. When making the decision for CPM, most had incomplete knowledge of potential negative outcomes. However, all believed CPM had more benefits than harms and would confer the most peace of mind and the fewest regrets should cancer return. They knew their contralateral breast cancer risk was low, but were not persuaded by statistics. They wanted to do everything possible to reduce their risk of another breast cancer, even by a minimal amount, but most reported paying an unexpectedly high price for this small reduction in risk. Nevertheless, 41 of 45 reported that they would make the same decision again.
Conclusions
These findings highlight an opportunity for physicians to reframe the conversation to focus on the patient experience of the tradeoffs of CPM rather than statistical odds of future cancers. Our findings suggest that more data may not dissuade women from CPM but may better prepare them for its outcomes.
... More women with early-stage, unilateral breast cancer and low genetic risk are choosing contralateral prophylactic mastectomy (CPM). [1][2][3][4][5][6][7][8][9][10][11] This trend is increasing, despite evidence that the risk for developing cancer in the healthy breast is low [2][3][4][5] and that removing the unaffected breast does not confer a survival advantage or quality of life benefit. 2 ...
152
Background: More women with early-stage unilateral breast cancer and low genetic risk are opting for CPM, despite their low risk of developing cancer in their healthy breast and evidence to demonstrate that CPM improves neither survival nor quality of life, while increasing the risk of surgical complications. Little is known about the factors that motivate this irreversible decision. Methods: We conducted comprehensive qualitative interviews with 42 women at low risk for contralateral breast cancer (CBC) who had CPM in the last 10 years. We recorded and transcribed the interviews and analyzed them using a grounded theory approach. Results: Contrary to hypotheses that newly diagnosed women overestimate their CBC risk, study patients knew of the low risk of cancer in their healthy breast, but still chose CPM. Statistics were unpersuasive; given healthy lifestyles and lack of risk factors, they felt unlucky to get breast cancer and feared they would be unlucky again. They believed CPM would give them more peace of mind and the fewest regrets should cancer return. Avoiding mammograms was important, given the potential for callbacks, biopsies, and more bad news. Avoiding radiation and wanting matching breasts were cited less often. Most were mainly focused on reducing their cancer risk and could not recall having critical information about CPM’s potential harms. A few knew of likely harms but misjudged their impact. When told of CPM’s higher risk of complications, most dismissed this as a disclaimer, believing they would get through surgery well. Despite experiencing negative effects of CPM, 38 of 42 stated they would make the same decision again. Conclusions: When choosing CPM, most women felt confident in making their decision, although many had incomplete knowledge of potential long-term impacts. Nevertheless the majority of women who chose CPM did not regret their decision, suggesting that women who elect CPM are selecting a treatment option that is consistent with their long-term personal values and preferences. While important to ensure women know potential long-term harms, our findings suggest they may not necessarily be dissuaded from CPM by more data, though they may be better prepared for it’s aftermath.
... This result is comparable to the population-based study by Falk et al. (n = 3,163; median follow-up 5.2 years) [15]. Despite the low cIBC risk, a marked increase in the use of contralateral prophylactic mastectomies among women with DCIS in recent years has been reported [40][41][42]. Because contralateral prophylactic mastectomies will not likely result in any survival advantage despite the minimization of cIBC risk [43] and are not risk-free [43][44][45], we advocate that prophylactic contralateral mastectomies for DCIS in women without hereditary breast cancer risk should be discouraged. ...
PurposeTo assess the effect of different treatment strategies on the risk of subsequent invasive breast cancer (IBC) in women diagnosed with ductal carcinoma in situ (DCIS). Methods
Up to 15-year cumulative incidences of ipsilateral IBC (iIBC) and contralateral IBC (cIBC) were assessed among a population-based cohort of 10,090 women treated for DCIS in the Netherlands between 1989 and 2004. Multivariable Cox regression analyses were used to evaluate associations of treatment with iIBC risk. ResultsFifteen years after DCIS diagnosis, cumulative incidence of iIBC was 1.9 % after mastectomy, 8.8 % after BCS+RT, and 15.4 % after BCS alone. Patients treated with BCS alone had a higher iIBC risk than those treated with BCS+RT during the first 5 years after treatment. This difference was less pronounced for patients <50 years [hazard ratio (HR) 2.11, 95 % confidence interval (CI) 1.35–3.29 for women <50, and HR 4.44, 95 % CI 3.11–6.36 for women ≥50, Pinteraction < 0.0001]. Beyond 5 years of follow-up, iIBC risk did not differ between patients treated with BCS+RT or BCS alone for women <50. Cumulative incidence of cIBC at 15 years was 6.4 %, compared to 3.4 % in the general population. Conclusions
We report an interaction of treatment with age and follow-up period on iIBC risk, indicating that the benefit of RT seems to be smaller among younger women, and stressing the importance of clinical studies with long follow-up. Finally, the low cIBC risk does not justify contralateral prophylactic mastectomies for many women with unilateral DCIS.
... 7,8,14 The rise in mastectomy rates reported in certain regions was associated with a concomitant increase in contralateral prophylactic mastectomy (CPM). 5,[22][23][24][25][26] However, bilateral mastectomy for unilateral breast cancer was not associated with lower mortality than BCT. 27 Predictors of receipt of ipsilateral mastectomy and CPM were found to be similar, and may be classified into patient factors, disease characteristics and those related to the healthcare provider or facility. ...
Since the results of randomised controlled trials in the last quarter of the twentieth century were reported, it has been conventionally accepted that breast conservation treatment (BCT) provides equivalent survival to mastectomy for early breast cancer. As expected, there was an initial fall in the use of mastectomy. The first decade of the twenty-first century, however, witnessed a trend of increasing mastectomy rates in some regions. This perplexing circumstance served as an impetus for a relook at survival outcomes with each surgical modality. Recent studies have demonstrated higher survival rates and improved local control associated with BCT. Such findings warrant a re-evaluation of treatment strategies, beginning with whether there is an optimum BCT rate.
... Studies in the past decade have shown a notable trend toward increased use of bilateral mastectomy for the treatment of early-stage breast cancer. [1][2][3][4][5][6] The largest study to date, based on the American College of Surgeons' National Cancer Data Base, estimates that in 2011, 11.2% of all women undergoing mastectomy for unilateral breast cancer chose to have contralateral prophylactic mastectomies (CPMs), increased from 1.9% in 1998. 7 The reasons underlying this trend are multifactorial, but likely include overestimates of recurrence risk, anxiety about future risk of new cancer, and improvements in breast reconstruction outcomes. ...
Purpose:
The rate of contralateral prophylactic mastectomies (CPMs) continues to rise, although there is little evidence to support improvement in quality of life (QOL) with CPM. We sought to ascertain whether patient-reported outcomes and, more specifically, QOL differed according to receipt of CPM.
Methods:
Volunteers recruited from the Army of Women with a history of breast cancer surgery took an electronically administered survey, which included the BREAST-Q, a well-validated breast surgery outcomes patient-reporting tool, and demographic and treatment-related questions. Descriptive statistics, hypothesis testing, and regression analysis were used to evaluate the association of CPM with four BREAST-Q QOL domains.
Results:
A total of 7,619 women completed questionnaires; of those eligible, 3,977 had a mastectomy and 1,598 reported receipt of CPM. Women undergoing CPM were younger than those who did not choose CPM. On unadjusted analysis, mean breast satisfaction was higher in the CPM group (60.4 v 57.9, P < .001) and mean physical well-being was lower in the CPM group (74.6 v 76.6, P < .001). On multivariable analysis, the CPM group continued to report higher breast satisfaction (P = .046) and psychosocial well-being (P = .017), but no difference was reported in the no-CPM group in the other QOL domains.
Conclusion:
Choice for CPM was associated with an improvement in breast satisfaction and psychosocial well-being. However, the magnitude of the effect may be too small to be clinically meaningful. Such patient-reported outcomes data are important to consider when counseling women contemplating CPM as part of their breast cancer treatment.
... 1,2 Increasing numbers of women with DCIS are electing contralateral prophylactic mastectomy (CPM), 2,3 with studies indicating a four-to five-fold increase in CPM in recent years. 4 In a study of 2,037 DCIS patients, 37% (<40 years) elected CPM, and 82% (<40 years) had immediate reconstruction. 3 Additionally, Ashfaq et al. found that a significantly higher proportion of patients undergoing CPM had reconstruction performed (46%) than those who did not elect CPM (15%). ...
The authors retrospectively examined the contralateral prophylactic mastectomy (CPM) rate among 100 women with ductal carcinoma in situ who are BRCA negative. Of 100 women with ductal carcinoma in situ, 31 elected contralateral prophylactic mastectomy (CPM). Factors associated with increased likelihood of undergoing contralateral prophylactic mastectomy (CPM) among this cohort were: family history of ovarian cancer, marital status, reconstruction, mastectomy of the affected breast, and tamoxifen use.
Background
Autologous breast reconstruction provides substantial benefits in terms of aesthetics and longevity. However, the risk of flap necrosis poses potential challenges to patients’ appearance and psychological well-being, while also escalating health care costs. Consequently, examining the risk factors, assessment techniques, and therapeutic approaches for flap necrosis is critically important.
Method
The authors conducted a comprehensive search for relevant studies from January 2010 to August 2024 using PubMed, Web of Science, and the Cochrane Library. The search terms included “autologous breast reconstruction”, “flap necrosis”, “risk factor”, “assessment”, and “treatment”. The authors initially screened titles and abstracts, followed by a detailed review by 3 investigators to determine the studies that met the inclusion criteria.
Result
A total of 68 studies were ultimately selected for analysis. Identified risk factors for flap necrosis include smoking, advanced age, obesity, diabetes, large breast volume, previous radiotherapy, and abdominal surgery. Various assessment methods (e.g., preoperative imaging, intraoperative blood flow monitoring, and postoperative evaluations) can enhance flap survival. The review also covered surgical treatment strategies and non-surgical interventions, including local wound care, hyperbaric oxygen therapy, and pharmacological treatments.
Conclusion
This review highlights the critical role of thorough planning and management in minimizing the risk of flap necrosis after autologous breast reconstruction. Effective preoperative assessments, perioperative monitoring, and specific postoperative interventions can significantly lower the incidence of flap necrosis.
Introduction:
Studies have shown a decrease in bilateral mastectomy (BM) rates over the past five to ten years, but it is not clear if these decreases are the same across different patient races.
Methods:
Using the National Cancer Database (NCDB) we examined BM rates for patients with AJCC Stage 0-II unilateral breast cancer from 2004 to 2020 for White versus nonwhite races (Blacks, Hispanics, and Asians). Multivariable logistic regression was used to identify patient and facility factors associated with BM by patient race from 2004 to 2006 and 2018-2020.
Results:
Of 1,187,864 patients, 791,594 (66.6%) had breast conserving surgery (BCS), 258,588 (21.8%) had unilateral mastectomy (UM) and 137,682 (11.6%) had BM. Our patient population was 927,530 (78.1%) White patients, 124,636 (10.5%) Black patients, 68,048 (5.7%) Hispanic patients, and 48,341 (4.1%) Asian patients. The BM rate steadily increased from 5.6% to 15.6% from 2004 to 2013, at which point the BM rate decreased to 11.3% in 2020. The decrease in BM was seen across all races, and in 2020, 6,487 (11.7%) Whites underwent BM compared to 506 (10.7%) Hispanics, 331 (9.2%) Asians, and 723 (9.1%) Blacks. Race was a significant independent factor for BM in 2004-2006 and 2018-2020 but all races were more likely to undergo BM in 2004 compared to 2020 after adjusting for patient and facility factors. Compared to Whites, the odds of undergoing BM were OR 0.41 (0.37-0.45) in 2004 compared to OR 0.66 (0.63-0.69) in 2020 for Blacks, OR 0.44 (0.38-0.52) and OR 0.61 (0.57-0.65) for Asians and OR 0.59 (0.52-0.66) and OR 0.71 (0.67-0.75) for Hispanics, respectively.
Conclusion:
BM rates for all races have declined since 2013, and differences in rates of BM amongst races have narrowed.
Contralateral prophylactic mastectomy (CPM) is a controversial breast cancer treatment in which both breasts are removed when only one is affected by cancer. Rates of CPM have been rising since the late 1990s, despite surgeons’ strong agreement that the procedure should not be performed for average-risk women. This essay analyses that agreement as it is demonstrated in the surgical literature on CPM, arguing that it forms a ‘rhetoric of certainty’ built on the stark epistemological divide between objective and subjective forms of knowledge that operates in some areas of medicine. Further, the essay argues that this rhetoric of certainty has the potential to function as a kind of eristic rhetoric in which the right conclusion is known prior to any rhetorical exchange. As a way to ‘crack open’ this certainty, the essay compares the rhetoric of the surgical literature on CPM to the rhetoric of uncertainty in the radiological literature on breast cancer screening for women with a personal history of the disease. The goal of this comparison is not to suggest surgeons should support all choices for CPM. Rather, the aim is to demonstrate that choices against the procedure are not as straightforward as the surgical literature indicates and that the uncertainty affecting women’s preferences for CPM is not solely the result of patient misunderstanding and/or emotional instability.
Background
There is an increasing desire for contralateral prophylactic mastectomy (CPM) among patients with unilateral breast cancer. It is unknown if risk assessment and genetic testing at the time of diagnosis will aid women in their surgical choice. We report on the uptake and predictors of CPM in women receiving a negative genetic test result for BRCA1 and BRCA2 mutations before surgery.Methods
Women diagnosed with breast cancer between June 2013 and May 2018 were recruited from four academic health sciences centers in Toronto, Canada. Genetic counseling (risk assessment) and genetic testing was performed prior to surgery. Women were asked about their surgical preference before surgery. At 1 year post-surgery we asked what surgery was completed. This study reports on women who received a negative BRCA1/BRCA2 result.ResultsA total of 766 women with a mean age of 46 years (range 21–82) were included in the analysis. Before genetic counseling and testing, 37% of the women were undecided or leaning towards CPM; however, after receiving a negative BRCA test, 15% of the women opted for CPM. Thirty percent of women whose mother died of breast cancer elected for CPM, compared with 15% of women whose mother did not die of breast cancer (p = 0.03).Conclusions
Women receiving a risk assessment and negative BRCA1/BRCA2 genetic test result before surgery use this information to guide their surgical decision. Uptake of CPM for women who were planning on CPM before genetic testing decreases after receiving a negative BRCA1/BRCA2 genetic test result.
Breast cancer is the most commonly diagnosed cancer and comes into prominence as a leading cause of death among women. Approximately 50% of the new cases globally are considered to be diagnosed in developed countries including Europe and the USA in 2020 (World Health Organisation, http://gco.iarc.fr/today/home, 2020). Breast cancer is a heterogeneous disease with multifactorial etiology depending on nongenetic and inherited risk factors. Genetic inheritance has long been documented as an increased risk factor since the identification of BRCA1 and BRCA2 genes. Germline mutations in BRCA1 and BRCA2 genes are presented in 3–4% of all women with breast cancer (Cancer Genome Atlas Network, Nature 490(7418):61–70, 2012; Ford et al., Am J Hum Genet 57(6):1457–1462, 1995). These mutations carry a lifetime risk of developing breast and/or ovarian cancer up to 7- and 25-fold increase according to that of the average risk group of patients (Tung et al., J Clin Oncol 38(18):2080–2106, 2020).
Purpose
Carriers of deleterious mutations in breast cancer predisposition genes are presented with critical choices regarding cancer risk management. Risk-reduction mastectomy is a major preventative strategy in this population. Understanding the decision-making process for prophylactic mastectomy is essential in patient-centered care for high-risk carriers and breast cancer patients. We sought to provide insight into influential factors underlying preventative surgery decisions among individuals with high breast cancer risk.
Methods
We conducted a retrospective chart review of pathogenic carriers in high-risk breast cancer genes who presented to the Moffitt GeneHome clinic, between March 2017 and June 2020. Associations between preventative mastectomy choice and influence variables were analyzed via unadjusted and adjusted logistic regression models.
Results
Of 258 high-risk mutation carriers, 104 (40.3%) underwent risk-reduction mastectomy. A significantly higher proportion of mastectomy patients reported prior history of breast cancer (68.9% versus 16.5%, p<0.001) and history of other risk-reduction or non-cancer related surgeries (61.7% versus 25.8%, p<0.001). Significant predictors affecting surgery decision included previous breast cancer history (aOR 10.48, 95%CI 5.59-19.63, p<0.0001), other risk-reduction or non-cancer related surgical history (aOR 4.65, 95%CI 2.28-9.47, p<0.0001), and age at presentation to the genetics clinic (<35 years old: aOR 2.77, 95% CI 1.04-7.4, p=0.042; 35-55 years old: aOR 2.48, 95% CI 1.19-5.18, p=0.016).
Conclusions
Preventive mastectomy decisions are highly personal and complex. In our sample, we observed prior history or concurrent breast cancer, history of other risk-reduction surgery or non-cancer related surgery, and younger age at presentation to the GeneHome clinic to be predictive of mastectomy uptake.
Background
The objective of this study is to examine racial differences in receipt of low‐value surgical care and time to surgery (TTS) among women receiving treatment at high‐volume hospitals.
Methods
Stage I–III non‐Hispanic Black (NHB) and Non‐Hispanic White (NHW) breast cancer patients were identified in the National Cancer Database. Low‐value care included (1) sentinel lymph node biopsy (SLNB) among T1N0 patients age ≥70 with hormone receptor–positive cancers, (2) axillary lymph node dissection (ALND) in patients meeting ACOSOG Z0011 criteria, and (3) contralateral prophylactic mastectomy (CPM) with unilateral cancer. TTS was days from biopsy to surgery. Bivariate and logistic regression analyses were used to compare the groups.
Results
Compared to NHWs, NHBs had lower rates of SLNB among women age ≥70 with small hormone–positive cancers (NHB 58.5% vs. NHW 62.2% p < .001) and CPM (NHB 26.3% vs. NHW 36%; p < .001). ALND rates for patients meeting ACOSOG Z0011 criteria were similar between both groups (p = .13). The odds of surgery >60 days were higher among NHBs (odds ratio, 1.77; 95% confidence interval, 1.64–1.91; NHW ref).
Conclusions
NHBs treated at high‐volume hospitals have higher rates of surgical delay but are less likely to undergo low‐value surgical procedures compared to NHW women.
Resumen
Objetivos
Evaluar las mastectomías reductoras de riesgo realizadas y analizar las indicaciones y resultados según las características individuales, oncológicas y quirúrgicas de nuestras pacientes.
Métodos
Estudio observacional retrospectivo de todas las mastectomías con reconstrucción inmediata en mamas sanas realizadas desde 2013 a 2019. Se dividieron las pacientes en tres grupos: I) riesgo genético de cáncer de mama, II) cáncer de mama diagnosticado y III) antecedente de cáncer de mama.
Resultados
Se realizaron 56 mastectomías reductoras de riesgo a 46 pacientes, 15% grupo I, 50% grupo II y 35% grupo III, pero tras estudios diferidos, 20 pacientes (43%) presentaban mutación genética. La media de edad en este subgrupo fue de 40 años y con predominio de tumores HER2+ (40% frente al 12%, p = 0,164). En el grupo III observamos más complicaciones inmediatas (31%, p = 0,014) y tardías (69%, p = 0,027) relacionadas con la reconstrucción protésica, y más evidente en mamas que tuvieron enfermedad (73% frente al 39% sanas, p = 0,002). Se encontró relación entre contractura capsular y la radioterapia postoperatoria (p = 0,008) y entre necrosis y radioterapia preoperatoria (p = 0,001). Se reintervino al 7% por complicaciones en mastectomías profilácticas. No hemos tenido recidivas locales.
Conclusiones
Consideramos justificada la mastectomía reductora de riesgo realizada a mujeres jóvenes con mutación genética y a pacientes con cáncer precoz, HER2+ y riesgo familiar. En pacientes ya tratadas por cáncer, el riesgo de complicaciones supera el valor profiláctico de la técnica. La reconstrucción mamaria es la principal responsable de complicaciones postoperatorias y las pacientes deben ser plenamente conscientes de ello.
Background
To address overuse of unnecessary practices, several surgical organizations have participated in the Choosing Wisely® campaign and identified four breast cancer surgical procedures as unnecessary. Despite evidence demonstrating no survival benefit for all four, evidence suggests only two have been substantially de-implemented. Our objective was to understand why surgeons stop performing certain unnecessary cancer operations but not others and how best to de-implement entrenched and emerging unnecessary procedures.Methods
We sampled surgeons who treat breast cancer in a variety of practice types and geographic regions in the United States. Using a semi-structured guide, we conducted telephone interviews (n = 18) to elicit attitudes and understand practices relating to the four identified breast cancer procedures in the Choosing Wisely® campaign. Interviews were recorded, transcribed, and anonymized. Transcripts were analyzed using inductive and deductive thematic analysis.ResultsFor the two procedures successfully de-implemented, surgeons described a high level of confidence in the data supporting the recommendations. In contrast, surgeons frequently described a lack of familiarity or skepticism toward the recommendation to avoid sentinel-node biopsy in women ≥ 70 years of age and the influence of other collaborating oncology providers as justification for continued use. Regarding contralateral prophylactic mastectomy, surgeons consistently agreed with the recommendation that this was unnecessary, yet reported continued utilization due to the value placed on patient autonomy and preference.Conclusions
With a growing focus on the elimination of ineffective, unproven or low value practices, it is imperative that the behavioral determinants are understood and targeted with specific interventions to decrease utilization rapidly.
Background
American Society of Breast Surgeons (ASBrS) guidelines state that it is the responsibility of the surgeon to discuss the risks/benefits of and give a recommendation regarding contralateral prophylactic mastectomy (CPM). We conducted a survey of ASBrS members to evaluate the factors that affect this recommendation, confidence in this recommendation, and awareness/adoption of the guidelines.
Methods
A survey was sent to the ASBrS membership. Vignettes with the following variables about breast cancer patient were randomly included: age, disease stage, receptor status, family history (FH) of breast cancer, and patient preference for CPM. Respondents were asked to estimate the patient’s chance of developing contralateral cancer, whether they would recommend CPM, and their confidence in this recommendation, and about their familiarity with and use of the guidelines.
Results
536 members (21.9%) responded. The odds of recommending CPM and confidence in recommendation were higher in a younger patient, higher-stage disease, triple-negative and human epidermal growth factor receptor (HER)2+ relative to estrogen receptor (ER)+, and in women with FH. Of surgeons, 51% were familiar or very familiar with the guidelines and 38% used the guidelines most or all of the time. Surgeons who used the guidelines were not less likely to recommend CPM.
Conclusions
While surgeons generally agree on the factors that are important in making a recommendation on CPM, there is variability in how strongly the different factors influence the recommendation and their confidence in that recommendation. In addition, while most surgeons were at least a little familiar with the ASBrS guidelines, the vast majority do not routinely use them.
Background
Increased use of contralateral prophylactic mastectomy (CPM) as treatment for ductal carcinoma in situ (DCIS) in the US was first noted in the early 2000s. Optimization of treatment guidelines for DCIS requires an understanding of current surgical treatment trends, particularly as they may differ by patient sociodemographic and community resource factors.
Objective
The aim of this study was to evaluate surgical treatment trends among US women with DCIS and to assess the impact of sociodemographic and community resource factors on surgical treatment choice.
Methods
The Surveillance, Epidemiology, and End Results dataset was queried for women aged 40 years and older who were diagnosed with unilateral DCIS between 2000 and 2014. Annual mastectomy rates were compared over time by age and race/ethnicity. Multivariable logistic regressions were performed to identify predictors of mastectomy use, with patient sociodemographics, tumor characteristics, and community resource factors (i.e. plastic surgeon density) as covariates.
Results
A total of 130,731 women with DCIS met the inclusion criteria. Overall mastectomy rates remained relatively unchanged over the study period (25–30%). CPM use increased for all age and race/ethnic groups, with the greatest increase exhibited by women aged 40–49 years [relative to 2000; 2014 odds ratio (OR) 10.6]. With respect to community resource factors, CPM use, as opposed to unilateral mastectomy, was associated with counties of higher education level (OR 1.52), higher income level (OR 1.22), and lower plastic surgeon density (OR 1.26).
Conclusion and Relevance
While the popularity of mastectomy in the management of DCIS has remained relatively unchanged since the turn of the century, the use of CPM has risen substantially. Younger women with DCIS have seen the greatest increase in CPM use, a choice that remains influenced by race/ethnicity as well as income, education, and health resource availability. Until clinical risk stratifiers of DCIS are identified, the surgical decision-making paradigm must be improved so that treatment choice remains sensitive to cultural differences but becomes independent of income, education, and health resource availability.
Unilateral thoracic paravertebral blocks (TPVBs) have demonstrated reliable intraoperative analgesia, low postoperative pain scores, and an opioid‐sparing effect in breast cancer surgery. However, secondary to the perceived risk of complications, bilateral TPVB have been less well accepted and are less frequently used. The purpose of this study was to evaluate the feasibility of using bilateral TPVBs in outpatient surgery for patients undergoing bilateral mastectomy with immediate implant‐based reconstruction. Electronic medical records were retrospectively reviewed for patients receiving bilateral TPVBs for bilateral mastectomy with immediate implant‐based reconstruction performed by a single surgeon from September 2012 to September 2015. Records were reviewed for incidence of complications, time to discharge, and incidence of unplanned admission or readmission. Clopper‐Pearson method for binomial distribution was used to calculate confidence intervals for proportions. Forty‐five patients undergoing bilateral mastectomy with immediate reconstruction received bilateral TPVBs. There were 4 TPVB‐related complications, all of which were symptomatic hypotension or bradycardia (9%; 95% CI, 2%‐21%). There was no incidence of symptomatic pneumothorax. Mean time to discharge readiness from the postanesthesia care unit (PACU) was 1.9 hours (SD = 1.0). Overall, 91% (n = 29) of the 32 patients scheduled for day surgery were discharged home as planned. Mean time from entry to PACU to home discharge for day surgery patients (n = 32) and planned admissions (n = 13) was 5.9 hours (SD = 4.3) and 16.3 hours (SD = 3.6), respectively. There was no incidence of readmission following discharge. Bilateral TPVBs can safely facilitate day surgery in carefully selected patients undergoing bilateral mastectomy with immediate implant‐based reconstruction.
Background:
Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution.
Methods:
We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction.
Results:
A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma.
Conclusions:
Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.
Introduction: The surgical techniques used in mastectomy are in constant evolution because of advancement in knowledge and the needs of patients. Methodology: Literature review of different types of mastectomy. Results: Halsted radical mastectomy (RM), the first effective surgery in treating breast cancer, was later modified by Patey, Madden, and others to preserve the pectoralis major muscle. Studies showed comparable survival outcomes between the two types of mastectomy. The modified radical mastectomy (MRM) became the standard treatment for women with stage I and II breast cancer in the 1970s. However, the axillary lymph node dissection (ALND), a part of modified radical mastectomy, was associated with significant side effects. Hence, the simple mastectomy (SM) was developed to spare the ALND and focus on treating the local disease only. Studies showed that survival after SM with or without radiation was comparable to those with RM. Recently, adjuvant systemic treatment has been shown to significantly improve disease-free and overall survival in patients with node-positive breast cancer, which requires nodal staging to guide therapy. Sentinel lymph node biopsy (SLNB) was invented to provide adequate pathologic nodal status in clinically negative axilla. Today, SM coupled with SLNB has largely replaced the MRM. Additional modifications to mastectomy by sparing the skin and the nipple areolar complex further increased its popularity. Discussion: The evolution of surgical treatment of breast cancer is governed by the principles of controlling the local disease and providing adequate pathology with minimal adverse effects. The validity of any new procedure requires confirmation.
Background:
Prophylactic or 'risk-reducing' mastectomy refers to the procedure of completely removing a healthy breast in order to reduce the risk of developing breast cancer. This may be bilateral or may be performed to the contralateral breast as part of the treatment of a proven breast cancer. The rate of this procedure being performed has been shown to be increasing over the last two decades. Recent guidance for Breast clinicians has been issued over the last 12 months by both The Association of Breast Surgery of Great Britain and Ireland (ABSGBI) and the American Society of Breast Surgeons (ASBrS). This review aims to look at the evidence behind the current decision making for patients requesting to undergo this increasingly popular procedure.
Method:
We undertook a review of the relevant literature via Medline using the PubMed interface for the key words 'Breast Cancer', 'Mastectomy', 'Prophylactic', 'Contra-lateral' and 'Risk-reducing' for papers from October 1991 to 2016. The Association of Breast Surgery guidance on the topic was published this year and was therefore included and referenced. Following review of the evidence, we have categorised patients into different groups, based on their background and evidence currently available to support the decision.
Results:
Clear evidence exists to support offering contralateral prophylactic mastectomy (CPM) to women who are high-risk gene carriers for Breast cancer. For those without, no survival benefit is evident however other quality of life measures may be improved with access to the procedure.
Conclusion:
For those women who are not high-risk gene carriers for breast cancer but have other factors that may increase their risk (strong family history, tumour characteristics) more evidence is needed as the benefit of CPM and all decisions to undertake it should occur through a multidisciplinary team approach.
Introduction:
Contralateral prophylactic mastectomy (CPM) rates are rising, with fear implicated as a contributing factor. This study used a contralateral breast cancer (CBC) risk stratification tool to assess whether the selection of CPM is reflective of future CBC risk.
Patients and methods:
This retrospective study evaluated 404 women with unilateral breast cancer treated with breast conservation, unilateral mastectomy, or bilateral mastectomy within a single multidisciplinary clinic. Women were evaluated by the Manchester risk tool to calculate lifetime CBC risk. Logistic regression analysis was used to evaluate whether CBC risk was associated with CPM, and the clinical rationale for prophylactic mastectomy justification was recorded.
Results:
Sixty-two percent underwent breast conservation, 18% unilateral mastectomy, and 20% bilateral mastectomy. In the CPM cohort, 36% had > 20% calculated lifetime CBC risk. In the invasive cohort, younger age (odds ratio 2.65, P < .0001) and genetic mutation positivity (odds ratio 35.39, P = .019) independently predicted CPM. Other contributing factors included benign contralateral breast findings (29%) and recommendations against breast conservation due to disease burden (28%). Six percent selected CPM as a result of an unsubstantiated fear regarding breast cancer.
Conclusion:
The majority of women (63%) who selected CPM had < 20% CBC risk. In these lower-risk women selecting CPM, factors increasing reasonable fear dominated surgical choice (81% of this subset).
Background:
Adjuvant hormonal therapy (HT) reduces breast cancer recurrence risk in estrogen receptor-positive (ER+) ductal carcinoma in situ (DCIS). We assessed national practice patterns and influence of surgery and pathology on HT use in DCIS.
Methods:
Data on DCIS patients diagnosed from 2004 to 2014 were extracted from the National Cancer Database, and patients were classified according to ER status and whether HT was received. Factors associated with HT use were assessed using Chi square tests for univariate analysis and logistic regression for multivariate analysis.
Results:
Overall, 207,738 patients were evaluable as follows: ER+ (69.3%), ER- (13.7%), and ER unknown (17.0%). Among ER+ DCIS patients, 46.5% received HT, and HT use increased over time (42.3% in 2004 to 50.6% in 2014; p < 0.001). In contrast, 7.8% of ER- DCIS patients received HT, decreasing from 10.7% in 2004 to 5.9% in 2014 (p < 0.001). HT use varied by surgery type (BCS, 53.9%; unilateral mastectomy, 31.5%; and bilateral mastectomy, 8.1%; p < 0.001) and use was higher in BCS patients receiving adjuvant radiation than those not receiving radiation (62.7 vs. 29.1%; p < 0.001). Males treated with BCS were less likely to receive HT than females (43.2 vs. 54.0%; p < 0.001). In the BCS subset, higher use of HT was associated with more recent calendar year, age between 40 and 80 years, female sex, positive progesterone receptor status, and radiation use.
Conclusion:
Adjuvant HT use in ER+ DCIS has increased over time, with the highest rates in patients treated with BCS and radiation. While inappropriate HT use was observed in ER- and bilateral mastectomy patients, the frequency of use in these categories decreased over time.
Objective
To examine temporal trends in guideline adherence for breast cancer local therapy, by race/ethnicity, socioeconomic and insurance status.
Background
Treatment guidelines recommend breast conserving therapy (BCT) for women with small cancers, but have been unevenly applied. A better understanding of time-trends in guideline adherence may point to interventions for correction.
Methods
Patients with tumors ≤2 cm (n = 1,081,075) were identified from 1123 NCDB hospitals, dividing the interval 1998–2011 into 5 segments. Significant differences in rates of guideline adherence over time for race/ethnicity, quartiles of income, education, and insurance status were identified using Chi-square tests. Random effects logistic regression was used to compute odds ratios (OR) for the likelihood of guideline adherence controlling for sociodemographic and clinical characteristics, hospital type and region.
Results
Multivariate models revealed disparities in use of BCT for women ≤39 years (OR 0.49, 95% CI 0.48–0.50); for Asians (OR 0.67, 95% CI 0.65–0.69); for women in the lowest education quartile (OR 0.89, 95% CI 0.87–0.91); and for women in rural regions, (OR 0.79 95% CI 0.76–0.81). The largest radiotherapy disparity was for the oldest women (OR 0.37, 95%CI 0.37–0.38), and in rural regions OR 0.67, 95% CI 0.63–0.71. Over time, differences persisted in BCT use (for race, income, education, insurance type); and for endocrine therapy (by race and education).
Conclusion
There was mixed progress in reducing disparities in guideline adherence. These results are conservative, since the most favorable tumor stages were analyzed in the NCDB, which reflects higher quality of care than non-participating hospitals.
Background
The use of contralateral prophylactic mastectomy (CPM) for women with unilateral breast cancer is increasing. The authors were interested in assessing whether this trend extended to patients with T4 disease.
Methods
We identified 92 patients from our prospective breast surgery registry with unilateral clinical T4 M0 disease who underwent mastectomy at our institution from October 2008 to July 2015. Patient, tumor, and treatment variables were compared between patients who did and those who did not undergo CPM, and the reasons patients elected CPM were ascertained.
Results
Of the 92 patients, 33 (36 %) underwent a CPM, including 25 of 55 patients (45 %) with inflammatory breast cancer. Immediate breast reconstruction was performed for 11 of the 92 patients (12 %), including 4 CPM patients. Pathology showed benign findings in all 33 CPM cases, including 3 patients with atypical hyperplasia. The primary reason for CPM reported by the patients included fear of occult current or future breast cancer in 12 cases (36 %), symmetry in 11 cases (33 %), avoidance of future chemotherapy in 5 cases (15 %), deleterious BRCA mutation in 2 cases (6 %), contralateral benign breast disease in 2 cases (6 %), and medical oncologist recommendation in 1 cases (3 %). Patients selecting CPM were younger and more likely to have undergone BRCA testing.
Conclusions
A substantial rate of CPM was observed among women undergoing mastectomy for unilateral T4 breast cancer despite the considerable risk of mortality from their index cancer. The reasons for selection of CPM paralleled those reported for patients with early-stage disease. The most common motivation was fear of occult current or future breast cancer and included the desire to avoid further chemotherapy.
Background:
Implant-based reconstruction is the predominant form of breast reconstruction with two-staged tissue expander/implant approach being the most popular. Recently, direct-to-implant, one-stage breast reconstruction procedure has gained momentum. In this study national and regional trends across the US for the two different types of implant-based reconstructions were evaluated.
Methods:
The Nationwide Inpatient Sample (NIS) database was used to extrapolate data on type of mastectomy, implant-based reconstructive technique (one-stage/two-staged), and sociodemographic and hospital variables. Differences were assessed using chi-square, impact of variables on reconstructive method was analyzed using logistic regression and trends were analyzed using Cochrane-Armitage test.
Results:
Between 1998 and 2012, a total of 1,444,587 patients treated for breast cancer or at increased risk of breast cancer met the defined selection criteria. Of these, 194,377 patients underwent implant-based breast reconstruction (13.6% one-stage and 86.4% two-staged). In both, there was a significant increase in procedures performed over time (p<0.001). The highest increase in both was seen in the Northeast region of the US, and the lowest in the Southern region. When stratified into regions, analysis showed differences in socio-economic and hospital characteristics within the different regions.
Conclusion:
There is an observed increase in the number of one-stage and two-staged breast reconstructions being performed. Sociodemographic and hospital factors of influence vary in the different regions of the USA. This study provides important information for clinicians and policy-makers who seek to ensure equitable and appropriate access for patient to the different types of implant-based procedures.
To examine the incidence and characteristics of metachronous contralateral breast cancer (CBC) among women in the Canton of Zurich, Switzerland.
For 1980-2006, patients with unilateral invasive breast cancer (UBC) were analysed for metachronous CBC. Poisson's regression was used to estimate incidence rates of metachronous CBC according to age, year of diagnosis, follow-up period since first breast cancer and morphology.
Of 16,323 patients with UBC, 700 (4.3 %) developed a second malignant tumour of the opposite breast. Median age at first breast cancer was lower in the CBC group than in the full cohort. Median interval time between first and second breast cancer was 5.5 (interquartile range 2.6-10.1) years. Incidence rate at age 20-29 was 1006 (95 % confidence interval, CI, 452-2238) cases per 100,000 person-years and decreased to 299 (199-450) at 80-84. Age-adjusted incidence rates according to period of diagnosis decreased from 618 (530-721) for 1980-1984 to 329 (217-500) cases per 100,000 person-years for 2005-2006. Incidence rate ratio of CBC for lobular carcinoma was 1.28 (95 % CI 0.99-1.67) adjusted by age group and period of diagnosis compared to ductal carcinoma.
In our study, incidence rates for CBC are comparable with findings from the literature. A reduction in the incidence of metachronous CBC, thought to be due to adjuvant therapies, is seen in our data. In our cohort, younger age and lobular carcinoma were associated with an increased risk of CBC.
Recent studies indicate that women with unilateral breast cancer are choosing contralateral prophylactic mastectomy (CPM) at an increasing rate. There is limited literature evaluating the postoperative complication rates associated with CPM without breast reconstruction. The objective of this study was to compare postoperative complications in women undergoing unilateral mastectomy (UM) and sentinel lymph node biopsy (SLNB) to those undergoing bilateral mastectomy (BM) and SLNB for the treatment of their breast cancer.
The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Participant Use Files between 2007 and 2010 were used to identify women with breast cancer undergoing UM or BM with SLNB. Individual and composite end points of 30-day complications were used to compare both groups by univariate and multivariate analyses.
We identified 4,219 breast cancer patients who had a SLNB: 3,722 (88.2 %) had UM and 497 (11.8 %) had BM. The wound complication rate was significantly higher in the BM group versus the UM group, 5.8 % versus 2.9 % [unadjusted odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.3-3.3, P < 0.01]. The overall 30-day complication rate in UM patients was 4.2 % versus 7.6 % in the BM group (unadjusted OR 1.9, 95 % CI 1.3-2.7, P < 0.01). The adjusted OR for overall complications adjusting for important patient characteristics was 1.9 (95 % CI 1.3-2.8, P < 0.01). Independent predictors of overall postoperative complications were body mass index (OR 1.1, P < 0.01) and smoking (OR 2.2, P < 0.01).
For patients with breast cancer, bilateral mastectomy is associated with an increased risk of wound and overall postoperative complications. Discussion of these outcomes is imperative when counseling women contemplating CPM.
BRCA1/2 mutation carriers with breast cancer are at high risk of contralateral disease. Such women often elect to have contralateral risk-reducing mastectomy (CRRM) to reduce the likelihood of recurrence. This study considers whether CRRM improves overall survival. 105 female BRCA1/2 mutation carriers with unilateral breast cancer who underwent CRRM were compared to controls (593 mutation carriers and 105 specifically matched) not undergoing CRRM and diagnosed between 1985 and 2010. Survival was assessed by proportional hazards models, and extended to a matched analysis using stratification by risk-reducing bilateral salpingo-oophorectomy (RRBSO), gene, grade and stage. Median time to CRRM was 1.1 years after the primary diagnosis (range 0.0-13.3). Median follow-up was 9.7 years in the CRRM group and 8.6 in the non-CRRM group. The 10-year overall survival was 89 % in women electing for CRRM (n = 105) compared to 71 % in the non-CRRM group (n = 593); p < 0.001. The survival advantage remained after matching for oophorectomy, gene, grade and stage: HR 0.37 (0.17-0.80, p = 0.008)-CRRM appeared to act independently of RRBSO. CRRM appears to confer a survival advantage. If this finding is confirmed in a larger series it should form part of the counselling procedure at diagnosis of the primary tumour. The indication for CRRM in women who have had RRBSO also requires further research.
Purpose:
Studies demonstrate an increasing rate of contralateral prophylactic mastectomy (CPM). The purpose of this study is to evaluate decision making and factors influencing women's long-term satisfaction with CPM. Descriptive analysis is used to analyze the results of our designed questionnaire approved by our Institutional Review Board.
Methods:
We searched our institutional cancer registry for patients diagnosed with breast cancer between 2000 and 2010. The studied time frame is of significance as this study is the first to measure response rate in questions examining patient satisfaction for >1 year after undergoing CPM. The questionnaire was mailed to all consented participants to examine factors contributing to the choice of CPM and postoperative satisfaction.
Results:
Of the 206 women included in the study, 147 were aged up to 50 years. Majority of women who underwent CPM in this cohort was with a bachelor's degree or higher, married or partnered women, and women earning >$60,000/y. Almost all women were "happy with overall surgery" and would recommend CPM to other patients. Psychological factors, such as fear of recurrence, were more commonly associated with the decision for CPM in patients with invasive carcinoma. Opinions of partners, relatives, friends, and physicians further contributed to the decision to undergo surgery. The availability of reconstruction was also an influential factor in the overall decision.
Conclusions:
The majority of our study participants experienced long-term satisfaction with the surgical procedure of CPM. From our analysis, we can confidently say that fear of cancer recurrence and the opinions of others, among other factors, were influencing contributors toward the decision of undergoing CPM.
BACKGROUND
Women with unilateral breast carcinoma are at increased risk for developing contralateral breast carcinoma (CBC). The authors sought to identify predictors of malignant or moderate to high-risk histologic findings in contralateral prophylactic mastectomy (CPM) specimens, and to determine the efficacy of CPM.METHODS
The authors performed a retrospective review of 239 patients with unilateral early-stage breast carcinoma who underwent CPM. The number of CBCs expected if the contralateral breast had been left intact was calculated based on CBC rates observed in the Surveillance, Epidemiology, and End Results (SEER) database and on life-table analysis by family history.RESULTSIn the current study, 11 patients (4.6%) had occult contralateral malignancies (4 invasive carcinomas and 7 ductal carcinomas in situ) and 44 (18.4%) patients had moderate to high-risk pathology (8 lobular carcinoma in situ, 11 atypical lobular hyperplasia, 25 atypical ductal hyperplasia). At 1846 patient-years of follow-up, only 1 patient (0.4%) developed a new CBC compared with 11 expected cancers based on SEER data. One CBC was observed among 140 patients with a family history of breast carcinoma, compared with 16 expected cancers based on life-table analysis adjusted for adjuvant therapy. The determinants of significant findings at CPM were invasive lobular histology, estrogen and progesterone receptor positivity, additional ipsilateral moderate to high-risk pathology, and age > 40 years at cancer diagnosis.CONCLUSIONSCPM was associated with a low risk of subsequent development of breast carcinoma. Evaluation of histologic findings in the ipsilateral breast may help to predict the likelihood of significant disease in the contralateral breast and assist in risk stratification. Cancer 2004. © 2004 American Cancer Society.
The objective of this study was to estimate the risk of contralateral breast cancer in BRCA1 and BRCA2 carriers; and measure the extent to which host, family history, and cancer treatment-related factors modify the risk.
Patients were 810 women, with stage I or II breast cancer, for whom a BRCA1 or BRCA2 mutation had been identified in the family. Patients were followed from the initial diagnosis of cancer until contralateral mastectomy, contralateral breast cancer, death, or last follow-up.
Overall, 149 subjects (18.4%) developed a contralateral breast cancer. The 15-year actuarial risk of contralateral breast cancer was 36.1% for women with a BRCA1 mutation and was 28.5% for women with a BRCA2 mutation. Women younger than 50 years of age at the time of breast cancer diagnosis were significantly more likely to develop a contralateral breast cancer at 15 years, compared with those older than 50 years (37.6 vs 16.8%; P=0.003). Women aged <50 years with two or more first-degree relatives with early-onset breast cancer were at high risk of contralateral breast cancer, compared with women with fewer, or no first-degree relatives with breast cancer (50 vs 36%; P=0.005). The risk of contralateral breast cancer was reduced with oophorectomy (RR 0.47; 95% CI 0.30-0.76; P=0.002).
The risk of contralateral breast cancer risk in BRCA mutation carriers declines with the age of diagnosis and increases with the number of first-degree relatives affected with breast cancer. Oophorectomy reduces the risk of contralateral breast cancer in young women with a BRCA mutation.
Increasing numbers of women with breast cancer are electing for contralateral prophylactic mastectomy (CPM) to reduce the risk of developing contralateral breast cancer. The objective of this study was to identify factors that may affect a patient's decision to undergo CPM. We identified 2,504 women with stage 0 to III unilateral primary breast cancer who underwent breast surgery at our institution from January 2000 to August 2006 from a prospectively maintained database. We did logistic regression analyses to determine which factors were associated with undergoing CPM. Of 2,504 breast cancer patients, 1,223 (48.8%) underwent total mastectomy. Of the 1,223 patients who underwent mastectomy, 284 (23.2%) underwent immediate or delayed CPM. There were 33 patients (1.3%) who had genetic testing before the surgery, with the use of testing increasing in the latter years of the study (0.1% in 2000-2002 versus 2.0% in 2003-2006; P < 0.0001). Multivariable analysis revealed several factors that were associated with a patient undergoing CPM: age younger than 50 years, white ethnicity, family history of breast cancer, BRCA1/2 mutation testing, invasive lobular histology, clinical stage, and use of reconstruction. We identified specific patient and tumor characteristics associated with the use of CPM. Although genetic testing is increasing, most women undergoing CPM did not have a known genetic predisposition to breast cancer. Evidence-driven models are needed to better inform women of their absolute risk of contralateral breast cancer as well as their competing risk of recurrence from the primary breast cancer to empower them in their active decision making.
After the National Institutes of Health Consensus Statement in 1990, breast-conserving surgery (BCS) became more common while mastectomy rates decreased. However, several recently published single-institution studies have reported an increase in mastectomy rates in the past decade. We conducted a population-based study to evaluate national trends in the surgical treatment of breast cancer from 2000 through 2006.
Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of women undergoing surgical treatment for breast cancer. We evaluated variation in mastectomy rates by demographic and tumor factors and calculated differences in mastectomy rates across time. We utilized logistic regression to identify time trends and patient and tumor factors associated with mastectomy, testing for significance using two-sided methods.
We identified 233,754 patients diagnosed with ductal carcinoma in situ or stage I to III unilateral breast cancer from 2000 to 2006. The proportion of women treated with mastectomy decreased from 40.8% in 2000 to 37.0% in 2006 (P < .001). These patterns were maintained across patient and tumor factors. Although the unilateral mastectomy rate decreased during the study period, the contralateral prophylactic mastectomy rate increased. Women were less likely to receive mastectomy over time (odds ratio, 1.18 for 2000 v 2006; 95% CI, 1.14 to 1.23; P < .0001), after adjusting for patient and tumor factors.
In contrast to single-institution studies, our population-based analysis found a decrease in unilateral mastectomy rates from 2000 to 2006 in the United States. Variations in referral patterns and patient selection are potential explanations for these differences between single institutions and national trends.
Women with BRCA1/2 mutations inherit high risks of breast and ovarian cancer; options to reduce cancer mortality include prophylactic surgery or breast screening, but their efficacy has never been empirically compared. We used decision analysis to simulate risk-reducing strategies in BRCA1/2 mutation carriers and to compare resulting survival probability and causes of death.
We developed a Monte Carlo model of breast screening with annual mammography plus magnetic resonance imaging (MRI) from ages 25 to 69 years, prophylactic mastectomy (PM) at various ages, and/or prophylactic oophorectomy (PO) at ages 40 or 50 years in 25-year-old BRCA1/2 mutation carriers.
With no intervention, survival probability by age 70 is 53% for BRCA1 and 71% for BRCA2 mutation carriers. The most effective single intervention for BRCA1 mutation carriers is PO at age 40, yielding a 15% absolute survival gain; for BRCA2 mutation carriers, the most effective single intervention is PM, yielding a 7% survival gain if performed at age 40 years. The combination of PM and PO at age 40 improves survival more than any single intervention, yielding 24% survival gain for BRCA1 and 11% for BRCA2 mutation carriers. PM at age 25 instead of age 40 offers minimal incremental benefit (1% to 2%); substituting screening for PM yields a similarly minimal decrement in survival (2% to 3%).
Although PM at age 25 plus PO at age 40 years maximizes survival probability, substituting mammography plus MRI screening for PM seems to offer comparable survival. These results may guide women with BRCA1/2 mutations in their choices between prophylactic surgery and breast screening.
Recent changes have occurred in the presurgical planning for breast cancer, including the introduction of preoperative breast magnetic resonance imaging (MRI). We sought to analyze the trends in mastectomy rates and the relationship to preoperative MRI and surgical year at Mayo Clinic, Rochester, MN.
We identified 5,405 patients who underwent surgery between 1997 and 2006. Patients undergoing MRI were identified from a prospective database. Trends in mastectomy rate and the association of MRI with surgery type were analyzed. Multiple logistic regression was used to assess the effect of surgery year and MRI on surgery type, while adjusting for potential confounding variables.
Mastectomy rates differed significantly across time (P < .0001), and decreased from 45% in 1997% to 31% in 2003, followed by increasing rates for 2004 to 2006. The use of MRI increased from 10% in 2003% to 23% in 2006 (P < .0001). Patients with MRI were more likely to undergo mastectomy than those without MRI (54% v 36%; P < .0001). However, mastectomy rates increased from 2004 to 2006 predominantly among patients without MRI (29% in 2003% to 41% in 2006; P < .0001). In a multivariable model, both MRI (odds ratio [OR], 1.7; P < .0001) and surgical year (compared to 2003 OR: 1.4 for 2004, 1.8 for 2005, and 1.7 for 2006; P < .0001) were independent predictors of mastectomy.
After a steady decline, mastectomy rates have increased in recent years with both surgery year and MRI as significant predictors for type of surgery. Further studies are needed to evaluate the role of MRI and other factors influencing surgical planning.
Data on the efficacy of bilateral prophylactic mastectomy for breast cancer risk reduction in women with BRCA1 and BRCA2 (BRCA1/2) mutations are limited, despite the clinical use of this risk-management strategy. Thus, we estimated the degree of breast cancer risk reduction after surgery in women who carry these mutations.
Four hundred eighty-three women with disease-associated germline BRCA1/2 mutations were studied for the occurrence of breast cancer. Cases were mutation carriers who underwent bilateral prophylactic mastectomy and who were followed prospectively from the time of their center ascertainment and their surgery, with analyses performed for both follow-up periods. Controls were BRCA1/2 mutation carriers with no history of bilateral prophylactic mastectomy matched to cases on gene, center, and year of birth. Both cases and controls were excluded for previous or concurrent diagnosis of breast cancer. Analyses were adjusted for duration of endogenous ovarian hormone exposure, including age at bilateral prophylactic oophorectomy if applicable.
Breast cancer was diagnosed in two (1.9%) of 105 women who had bilateral prophylactic mastectomy and in 184 (48.7%) of 378 matched controls who did not have the procedure, with a mean follow-up of 6.4 years. Bilateral prophylactic mastectomy reduced the risk of breast cancer by approximately 95% in women with prior or concurrent bilateral prophylactic oophorectomy and by approximately 90% in women with intact ovaries.
Bilateral prophylactic mastectomy reduces the risk of breast cancer in women with BRCA1/2 mutations by approximately 90%.
The clinical outcome of contralateral prophylactic mastectomy (CPM) in women with a BRCA1 or BRCA2 mutation and a personal history of invasive breast cancer is unknown. We identified a cohort of 148 female BRCA1 or BRCA2 mutation carriers (115 and 33, respectively) who previously were treated for unilateral invasive breast cancer stages I-IIIa. In all, 79 women underwent a CPM, while the other women remained under intensive surveillance. The mean follow-up was 3.5 years and started at the time of CPM or at the date of mutation testing, whichever came last, that is, on average 5 years after diagnosis of the first breast cancer. One woman developed an invasive contralateral primary breast cancer after CPM, whereas six were observed in the surveillance group (P<0.001). Contralateral prophylactic mastectomy reduced the risk of contralateral breast cancer by 91%, independent of the effect of bilateral prophylactic oophorectomy (BPO). At 5 years follow-up, overall survival was 94% for the CPM group vs 77% for the surveillance group (P=0.03), but this was unexpectedly mostly due to higher mortality related with first breast cancer and ovarian cancer in the surveillance group. After adjustment for BPO in a multivariate Cox analysis, the CPM effect on overall survival was no longer significant. Our data show that CPM markedly reduces the risk of contralateral breast cancer among BRCA1 or BRCA2 mutation carriers with a history of breast cancer. Longer follow-up is needed to study the impact of CPM on contralateral breast cancer-specific survival. The choice for CPM is highly correlated with that for BPO, while only BPO leads to a significant improvement in overall survival so far.
Women affected with breast cancer who carry a BRCA1 or BRCA2 (BRCA1/2) mutation are at risk of developing contralateral breast cancer. To reduce the risk of contralateral breast cancer, some patients opt for prophylactic surgery of the unaffected breast (contralateral prophylactic mastectomy, CPM) in addition to mastectomy of the affected breast.
We conducted the present study to determine the predictors and outcomes of CPM in the year following BRCA1/2 genetic counseling and testing. Four hundred and thirty-five women affected with unilateral breast cancer who received positive or uninformative BRCA1/2 genetic test results completed assessments prior to genetic counseling and testing and 1, 6, and 12 months after receipt of results.
Prior to testing, 16% had undergone CPM (in conjunction with mastectomy of the affected breast). In the year following testing, 18% with positive test results and 3% with uninformative test results opted for CPM. CPM following testing was associated with a positive genetic test result, younger age at cancer diagnosis [odds ratio (OR) = 0.94], and higher cancer-specific distress at baseline (OR = 3.28). CPM was not associated with distress outcomes at 12 months.
Following a positive test result, 18% of women previously affected with unilateral breast cancer had a CPM. Women affected with breast cancer at a younger age, particularly those with positive genetic test results and higher cancer-specific distress, are more likely to choose CPM than women who receive uninformative test results and who are less distressed and older at diagnosis. CPM does not appear to impact distress outcomes.
To evaluate the rate of prophylactic contralateral mastectomy in an international cohort of women with hereditary breast cancer and to evaluate the predictors of uptake of preventive surgery.
Women with a BRCA1 or BRCA2 mutation who had been diagnosed with unilateral breast cancer were followed prospectively for a minimum of 1.5 years. Information was collected on prophylactic surgery, tamoxifen use, and the occurrence of contralateral breast cancer.
Nine hundred twenty-seven women were included in the study; of these, 253 women (27.3%) underwent a contralateral prophylactic mastectomy after the initial diagnosis of breast cancer. There were large differences in uptake of contralateral prophylactic mastectomy by country, ranging from 0% in Norway to 49.3% in the United States. Among women from North America, those who had a prophylactic contralateral mastectomy were significantly younger at breast cancer diagnosis (mean age, 39 years) than were those without preventive surgery (mean age, 43 years). Women who initially underwent breast-conserving surgery were less likely to undergo contralateral prophylactic mastectomy than were women who underwent a mastectomy (12% v 40%; P < 10(-4)). Women who had elected for a prophylactic bilateral oophorectomy were more likely to have had their contralateral breast removed than those with intact ovaries (33% v 18%; P < 10(-4)).
Age, type of initial breast cancer surgery, and prophylactic oophorectomy are all predictive of prophylactic contralateral mastectomy in women with breast cancer and a BRCA mutation. The acceptance of contralateral preventive mastectomy was much higher in North America than in Europe.
Context Women with BRCA1- or BRCA2-associated breast cancer are at increased risk for contralateral breast
cancer and ovarian cancer and therefore may consider secondary cancer prevention
strategies, such as prophylactic surgery and tamoxifen therapy. It is not
proven to what extent these strategies reduce risk of second cancers in such
patients.
Objective To examine the effect of tamoxifen therapy, bilateral prophylactic oophorectomy
(PO), prophylactic contralateral mastectomy (PCM), and combinations of these
strategies on life expectancy for women with unilateral breast cancer and
a BRCA1 or BRCA2 gene mutation.
Design and Setting Decision analysis using a Markov model. Probabilities for developing
contralateral breast cancer and ovarian cancer, dying from these cancers,
dying from primary breast cancer, and the reduction in cancer incidence and
mortality due to prophylactic surgeries and/or tamoxifen were estimated from
published studies.
Participants Hypothetical breast cancer patients with BRCA1
or BRCA2 mutations facing decisions about secondary
cancer prevention strategies.
Interventions Seven strategies, including 5 years of tamoxifen use, PO, PCM, and combinations
of these strategies, compared with careful surveillance.
Main Outcome Measures Total and incremental life expectancy (LE) with each intervention strategy.
Results Depending on the assumed penetrance of the BRCA
mutation, compared with surveillance alone, 30-year-old early-stage breast
cancer patients with BRCA mutations gain in LE 0.4
to 1.3 years from tamoxifen therapy, 0.2 to 1.8 years from PO, and 0.6 to
2.1 years from PCM. The magnitude of these gains is least for women with low-penetrance
mutations (assumed contralateral breast cancer risk of 24% and ovarian cancer
risk of 6%) and greatest for those with high-penetrance mutations (assumed
contralateral breast cancer risk of 65% and ovarian cancer risk of 40%.) Older
age and poorer prognosis from primary breast cancer further attenuate these
gains.
Conclusions Interventions to prevent second cancers, particularly PCM, may offer
substantial LE gain for young women with BRCA-associated
early-stage breast cancer. Estimates of LE gain may help women and their physicians
consider the uncertainties, risks, and advantages of these interventions and
lead to more informed choices about cancer prevention strategies.
Recent studies have reported increases in the rate of mastectomy and contralateral prophylactic mastectomy (CPM). We hypothesized that there would be different reasons for choosing mastectomy for women aged <50 compared with those aged ≥50 years.
A questionnaire was administered to 332 patients who underwent unilateral or bilateral mastectomy for breast cancer from 2006 to 2010. The survey queried on demographics, surgical choices, and rationale for those choices. A retrospective chart review was performed to determine tumor characteristics. Responses and clinical characteristics were described by contingency tables and compared using Fisher exact test or χ(2) test, as appropriate.
Of 332 patients surveyed, 310 were evaluable. Median age was 55 years, including 88 patients <50 (28 %) and 222 patients ≥50 (72 %) at time of diagnosis. Forty-four percent of women <50 and 41 % of women ≥50 were given the option of breast conservation and chose mastectomy (p > 0.63). The two groups did not differ in their reason for choosing mastectomy, with lower recurrence risk and improved survival cited as the two most common reasons. Younger patients were more likely to undergo reconstruction and CPM (p < 0.0001) as well as have estrogen receptor-negative tumors, undergo neoadjuvant chemotherapy, and have higher magnetic resonance imaging utilization (p < 0.05).
Choosing mastectomy and the reasons for doing so were the same for women aged <50 and ≥50 years. Prospective studies are needed to determine whether patient education regarding perceived versus actual recurrence risk and survival would alter this decision-making process.
Invasive lobular carcinoma has been associated with an increased risk of contralateral breast disease. Controversy exists regarding the use of contralateral prophylactic mastectomy versus careful observation of the contralateral breast. Our objective was to determine the incidence of occult cancer in the contralateral breast and to assess whether contralateral prophylactic mastectomy improves patient survival. We retrospectively reviewed the charts of 133 patients treated surgically for invasive lobular carcinoma between January 1, 1978, and December 31, 1993. The median age was 54 years (range, 24–82 years). The distribution of patients by stage was as follows: stage 1, 29%; stage IIa, 36%; stage IIb, 20%; stage IIIa, 11%; stage IIIb, 3%; and unknown, 1%. The median follow-up was 68 months (range, 13–178 months). Group comparisons were performed using log-rank analysis and survival curves were constructed by the method of Kaplan and Meier. Eighteen patients underwent contralateral prophylactic mastectomy. Among these patients there were no cases of invasive cancer and only 3 (17%) cases of lobular carcinoma in situ in the contralateral breast. Three patients who underwent contralateral prophylactic mastectomy later developed distant metastases from the original ipsilateral breast cancer. Of the 115 patients managed conservatively, 3 (3%) developed contralateral disease at 11, 34, and 101 months. Twenty-five patients developed distant disease. Overall survival in the contralateral prophylactic mastectomy group did not differ significantly from the group treated conservatively (p = 0.90). We conclude that careful observation with a yearly mammogram and physical examination of the contralateral breast is appropriate management for patients with invasive lobular carcinoma.
The effect of contralateral prophylactic mastectomy (CPM) on the survival of patients with early-stage breast cancer remains controversial. The objective of this study was to evaluate the benefits of CPM using a propensity scoring approach that reduces selection bias from the nonrandom assignment of patients in observational studies.
A total of 3889 female patients with stage I to III breast cancer were identified who were treated at The University of Texas MD Anderson Cancer Center from 1997 to 2009. We assessed the association between CPM and disease-free (DFS) and overall survival (OS), by using Cox proportional hazards models to estimate hazard ratios (HRs), and by matching patients in the CPM and no-CPM groups using propensity scores (n = 497 pairs).
With a median follow-up time of 4.5 years, CPM was associated with improved DFS (HR, 0.75; 95% confidence interval [CI], 0.59-0.97) and OS (HR, 0.74; 95% CI, 0.56-0.99), adjusted for prognostic factors. The improved DFS was seen predominantly among hormone receptor–negative (HR, 0.60; 95% CI, 0.38-0.95) compared with hormone receptor–positive patients (HR, 0.80; 95% CI, 0.58-1.10). For the matched patient cohort, stratified survival analysis also showed an improvement in DFS with CPM (HR, 0.48; 95% CI, 0.22-1.01) in hormone receptor–negative patients that was nearly statistically significant.
CPM was associated with improved DFS for some patients with hormone receptor–negative breast cancer, after reducing selection bias. Identifying subsets of patients most likely to benefit from CPM may have important implications for a more personalized approach to treatment decisions about CPM. Cancer 2012.
Numerous recent studies conducted in the USA reported a considerable rise in the rates of contralateral prophylactic mastectomy (CPM) in early-stage breast cancer (BC). However, this aggressive surgical approach only showed an evidence-based improvement in prognosis for a small subgroup of high-risk BC patients. We present the first European study reporting CPM rates in an unselected cohort of patients with BC.
The data of 881 patients (≤ 80 years) who underwent surgery for stage I-III BC from 1995 to 2009 at the University of Basel Breast Center was analyzed.
CPM was performed in 23 of 881 patients (2.6%). Of the entire patient population, 37.5% underwent ipsilateral mastectomy and of those, only 7.0% chose to undergo CPM. Importantly, there was no trend over time in the rate of CPM. Women who chose CPM were significantly younger (54 vs. 60 years, p < 0.001), had more often a positive family history (39.1% vs. 24.4%, p = 0.032) and tumors of lobular histology (30.5% vs. 13.9%, p = 0.035).
Our analysis of CPM rates in BC patients, conducted at a European University breast center, does not show the considerably rising CPM rates observed in the USA. We hypothesize that different medico-social and cultural factors, which are highlighted by a different public perception of BC and a different attitude toward plastic surgery, determine the varying CPM rates between the USA and Europe.
Several studies have reported an increased rate of contralateral prophylactic mastectomy (CPM) in patients with unilateral breast cancer. This study reports on CPM trends from the American College of Surgeon's National Cancer Data Base (NCDB) diagnosed over a 10-year period.
Data about women diagnosed with unilateral breast cancer between 1998 and 2007 undergoing CPM were extracted from the NCDB. Temporal trends were analyzed across patient demographic, tumor, and provider characteristics. Logistic regression models identified characteristics independently associated with use of CPM.
A total of 1,166,456 patients, of whom 23,218 patients underwent CPM, were reviewed; use increased from 0.4% in 1998 to 4.7% in 2007 of surgically treated patients. The greatest comparative increases in CPM was among white patients <40 years of age residing in high socioeconomic status areas with private or managed care insurance plans and treated at high-volume medical centers in the Midwest region of the country. A greater proportion of patients with in-situ disease undergo CPM compared to invasive disease. Independent factors associated with CPM include patient demographic and socioeconomic factors, tumor stage and histopathology, and provider characteristics.
Although an increase in the proportion of surgically treated women undergoing CPM was universally observed across a broad range of patient, biological, and provider factors, the increase was more noticeably associated with patient-related factors rather than tumor or biological characteristics. Further studies are needed to determine why patients seem to choose CPM and whether a survival benefit can be associated with this choice of surgical management.
Despite increased demand for contralateral prophylactic mastectomy (CPM), the survival benefit of this procedure remains uncertain.
We used the Surveillance, Epidemiology, and End Results database to identify 107 106 women with breast cancer who had undergone mastectomy for treatment between 1998 and 2003 and a subset of 8902 women who also underwent CPM during the same period. Associations between predictor variables and the likelihood of undergoing CPM were evaluated by use of chi(2) analyses. Risk-stratified (estrogen receptor [ER] status, stage, and age) adjusted survival analyses were performed by using Cox regression. Statistical tests were two-sided.
In a univariate analysis, CPM was associated with improved disease-specific survival (hazard ratio [HR] of death = 0.63, 95% confidence interval [CI] = 0.57 to 0.69; P < .001). Risk-stratified analysis showed that this association was because of a reduction in breast cancer-specific mortality in women aged 18-49 years with stages I-II ER-negative cancer (HR of death = 0.68, 95% CI = 0.53 to 0.88; P = .004). Five year-adjusted breast cancer survival for this group was improved with CPM vs without (88.5% vs 83.7%, difference = 4.8%). Although rates of contralateral breast cancer among young women with stages I-II disease undergoing CPM were independent of ER status, women with ER-positive tumors in the absence of prophylactic mastectomy also had a lower overall risk for contralateral breast cancer than women with ER-negative tumors (0.46% vs 0.90%, difference = 0.44%; P < .001).
CPM is associated with a small improvement in 5-year breast cancer-specific survival mainly in young women with early-stage ER-negative breast cancer. This effect is related to a higher baseline risk of contralateral breast cancer.
Patients with unilateral breast cancer have an increased risk of developing contralateral breast cancer. A recent population-based study demonstrated that the proportion of patients with unilateral breast cancer in the United States who underwent contralateral prophylactic mastectomy (CPM) has increased by 150% in recent years. The current study evaluated patients who underwent breast cancer surgery in a metropolitan-based hospital system to determine factors associated with CPM.
We reviewed the records of all patients who underwent surgical treatment for breast cancer in 2006 and 2007 in a single health care system, which included six different hospitals. Exclusion criteria included preoperative diagnosis of bilateral disease, stage IV disease, and a history of previous breast cancer. We recorded patient, treatment, tumor, and surgeon characteristics. Multivariate logistic regression models were used to predict CPM use.
Of 571 eligible patients, 276 (48.3%) underwent breast-conserving surgery (BCS), 130 (22.8%) underwent unilateral mastectomy, and 165 (28.9%) underwent mastectomy and a CPM. Among mastectomy patients, 55.9% underwent CPM. Young age (<40 vs. >55 years), large tumor size (>5 vs. <2 cm), positive family history, lobular histology, multicentric disease, and surgeon gender (female) were independent predictors of increased CPM rates. Body mass index, tumor grade, estrogen receptor status, and preoperative breast magnetic resonance imaging were not associated with increased CPM rates.
Our study is the first to evaluate specific surgeon characteristics associated with CPM use. Prospective studies are needed to examine factors affecting patient decision-making to develop resources that may assist patients in this process.
Preoperative use of breast magnetic resonance imaging (MRI) in women with breast cancer may increase rates of mastectomy. This study investigated relationships between breast MRI and therapeutic and contralateral prophylactic mastectomy (CPM) in women with breast cancer.
A total of 3606 women diagnosed with stage 0-III breast cancer from 1998 through 2000 (n = 1743; early period) or from 2003 through 2005 (n = 1863; late period) were retrospectively identified. Patient demographic and clinical characteristics were obtained from our institution's tumor registry. MRI use in the diagnostic evaluation was obtained from a prospective radiology database. Rates of therapeutic mastectomy, CPM, and associations with breast MRI were compared between the two time periods by multiple logistic regressions controlling for disease stage, age, family history, and calendar year of diagnosis.
A total of 14.2% of women underwent MRI, 29.0% had mastectomy, and 5.3% had CPM. Use of breast MRI increased substantially between the two time periods (4.1% to 23.7%, P < 0.001). Mastectomy rates increased from 28% to 30% (P > 0.05). The rate of CPM increased by >50% from the early to late period (4.1% to 6.4%, P < 0.002). Women who underwent MRI were nearly twice as likely to have CPM (9.2 vs. 4.7%, P < 0.001). Multivariate models found MRI was associated with increased rates of CPM for women with stage I or II disease (odds ratio 2.04, P = 0.001).
MRI changes the surgical treatment of breast cancer among subsets of women diagnosed with breast cancer, suggesting there are hidden monetary and nonmonetary costs associated with its use.
Some women with unilateral ductal carcinoma in situ (DCIS) undergo contralateral prophylactic mastectomy (CPM) to prevent cancer in the opposite breast. The use and trends of CPM for DCIS in the United States have not previously been reported.
We used the Surveillance, Epidemiology, and End Results database to analyze the initial treatment (within 6 months) of patients with unilateral DCIS diagnosed from 1998 through 2005. We determined the CPM rate as a proportion of all surgically treated patients and as a proportion of all patients who underwent mastectomy. We compared demographic and tumor variables in women with unilateral DCIS who underwent surgical treatment.
We identified 51,030 patients with DCIS; 2,072 patients chose CPM. The CPM rate was 4.1% for all surgically treated patients and 13.5% for patients undergoing mastectomy. Among all surgically treated patients (including breast-conserving surgery), the CPM rate increased by 148% from 1998 (2.1%) to 2005 (5.2%). Among patients who underwent mastectomy to treat DCIS (excluding patients undergoing breast-conserving surgery), the CPM rate increased by 188% from 1998 (6.4%) to 2005 (18.4%). Young patient age, white race, recent year of diagnosis, and the presence of lobular carcinoma in situ were significantly associated with higher CPM rates among all surgically treated patients and all patients undergoing mastectomy. Large tumor size and higher grade were significantly associated with increased CPM rates among all surgically treated patients but lower CPM rates among patients undergoing mastectomy.
The use of CPM for DCIS in the United States markedly increased from 1998 through 2005.
Although contralateral prophylactic mastectomy (CPM) reduced the risk of contralateral breast cancer in unilateral breast cancer patients, it was difficult to predict which patients were most likely to benefit from the procedure. The objective of this study was to identify the clinicopathologic factors that predict contralateral breast cancer and thereby inform decisions regarding performing CPM in unilateral breast cancer patients.
A total of 542 unilateral breast cancer patients who underwent CPM at The University of Texas M. D. Anderson Cancer Center from January 2000 to April 2007 were included in the current study. A logistic regression analysis was used to identify clinicopathologic factors that predict contralateral breast cancer.
Of the 542 patients included in this study, 25 (5%) had an occult malignancy in the contralateral breast. Eighty-two patients (15%) had moderate-risk to high-risk histologic findings identified at final pathologic evaluation of the contralateral breast. Multivariate analysis revealed that 3 independent factors predicted malignancy in the contralateral breast: an ipsilateral invasive lobular histology, an ipsilateral multicentric tumor, and a 5-year Gail risk >or=1.67%. Multivariate analysis also revealed that an age >or=50 years at the time of the initial cancer diagnosis and an additional ipsilateral moderate-risk to high-risk pathology were independent predictors of moderate-risk to high-risk histologic findings in the contralateral breast.
The findings indicated that CPM may be a rational choice for breast cancer patients who have a 5-year Gail risk >or=1.67%, an additional ipsilateral moderate-risk to high-risk pathology, an ipsilateral multicentric tumor, or an ipsilateral tumor of invasive lobular histology.
The magnitude of the breast cancer problem is presented along with changing therapeutic concepts, the surgeon's role in breast cancer therapy, and therapeutic options including the evaluation studies by the National Surgical Adjuvant Breast Project.
The importance of selective surgery and the criteria utilized for choosing the appropriate procedure, as well as the currently most popular surgical procedure and the major selective surgical approaches are discussed. A moderate selective surgical approach is presented along with a discussion about the possible implementation of lesser surgical procedures.
The results in 1,147 patients with potentially curable breast cancers (Stage 0, 1 and 2), followed for ten or more years, 82.9% of which were treated by less than a radical procedure, with the most popular procedure being a modified radical mastectomy, are presented. The ten year absolute, no evidence of disease survival rate for the entire group of patients was 64.8%, and for the 1,062 patients with only invasive cancers it was 62.1%. The local recurrence rate for the entire group was 7.3%, with an axillary recurrence rate of 0.7%. Only 2.1% of the patients were skin grafted.
7.3% unsuspected cancers were found in a series of 561 random biopsies of the other breast, and 19.7% unsuspected cancers were found in 127 prophylactic contralateral mastectomies in patients who were in the high risk group for developing cancer in the remaining breast. The better cosmetic and functional result obtained with lesser surgical procedures is emphasized along with the discussion regarding reconstructive surgery. Finally, the results are compared to those obtained with other types of surgical approaches and with primary radiotherapy.
Management of the contralateral normal-appearing breast in a patient with ipsilateral invasive lobular carcinoma (ILC) is controversial.
The case histories of patients with histologically proven ILC who underwent definitive surgery at our institution from 1978 to 1991 were retrospectively reviewed.
Of the 419 women with ILC, 36 (8.6%) had bilateral cancer, with a cumulative risk of 10% at 10 years. Twenty-five (69%) of these cancers were suspected before operation. From 105 contralateral prophylactic surgical procedures, seven (64%) in-situ and four (36%) invasive cancers were detected. The age at presentation and multifocality of the index cancer were significantly different between patients with unilateral and those with bilateral cancers. No survival difference was noted between patients whose contralateral cancers were suspected clinically and those whose cancers were detected prophylactically. Survival rates between patients with unilateral versus bilateral cancers were also not different. However, patients with contralateral prophylactic surgery had a better prognosis than those with unilateral tumors and no prophylaxis.
Ten percent of patients with ILC experienced bilateral cancers during a period of 10 years. Survival was not influenced by the development of a second cancer, but it improved with surgical prophylaxis.
Patients with a history of carcinoma of one breast have an estimated risk of 0.5% to 0.75% per year of developing a contralateral breast cancer. This risk prompts many women to consider contralateral prophylactic mastectomy (CPM) as a preventive measure. Virtually nothing is known about patient acceptance following CPM. We have developed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic (unilateral or bilateral) mastectomy.
Of the 346 women with CPM who responded to national notices, 296 women returned detailed questionnaires. The information obtained included patient demographics, family history, reproductive history, ipsilateral breast cancer staging and treatment, as well as issues involving the CPM.
At median follow-up of 4.9 years, the respondents were primarily married (79%), white (97%) women who had some level of college education or above (81%). These women cited the following reasons for choosing CPM: (1) physician advice regarding the high risk of developing contralateral breast cancer (30%); (2) fear of developing more breast cancer (14%); (3) desire for cosmetic symmetry (10%); (4) family history (7%); (5) fibrocystic breast disease (4%); (6) a combination of all of these reasons (32%); (7) other (2%); and (8) unknown (1%). Eighteen of the 296 women (6%) expressed regrets regarding their decision to undergo CPM. Unlike women with bilateral prophylactic mastectomies, regrets tended to be less common in the women with whom the discussion of CPM had been initiated by their physician (5%) than in the women who had initiated the discussion themselves (8%) (P = ns). Family history and stage of index lesion had no impact on regret status. The reasons for regret included: (1) poor cosmetic result, either of the CPM or of the reconstruction (39%); (2) diminished sense of sexuality (22%); (3) lack of education regarding alternative surveillance methods or CPM efficacy (22%); and (4) other reasons (17%).
To minimize the risk of regrets in women contemplating CPM, it is imperative that these women be counseled regarding an estimation of contralateral breast cancer risk, the alternatives to CPM, and the efficacy of CPM. In addition, these women should have realistic expectations of the cosmetic outcomes of surgery and understand the potential impact on their body image.
Women with BRCA1- or BRCA2-associated breast cancer are at increased risk for contralateral breast cancer and ovarian cancer and therefore may consider secondary cancer prevention strategies, such as prophylactic surgery and tamoxifen therapy. It is not proven to what extent these strategies reduce risk of second cancers in such patients.
To examine the effect of tamoxifen therapy, bilateral prophylactic oophorectomy (PO), prophylactic contralateral mastectomy (PCM), and combinations of these strategies on life expectancy for women with unilateral breast cancer and a BRCA1 or BRCA2 gene mutation.
Decision analysis using a Markov model. Probabilities for developing contralateral breast cancer and ovarian cancer, dying from these cancers, dying from primary breast cancer, and the reduction in cancer incidence and mortality due to prophylactic surgeries and/or tamoxifen were estimated from published studies.
Hypothetical breast cancer patients with BRCA1 or BRCA2 mutations facing decisions about secondary cancer prevention strategies.
Seven strategies, including 5 years of tamoxifen use, PO, PCM, and combinations of these strategies, compared with careful surveillance.
Total and incremental life expectancy (LE) with each intervention strategy.
Depending on the assumed penetrance of the BRCA mutation, compared with surveillance alone, 30-year-old early-stage breast cancer patients with BRCA mutations gain in LE 0.4 to 1.3 years from tamoxifen therapy, 0.2 to 1.8 years from PO, and 0.6 to 2.1 years from PCM. The magnitude of these gains is least for women with low-penetrance mutations (assumed contralateral breast cancer risk of 24% and ovarian cancer risk of 6%) and greatest for those with high-penetrance mutations (assumed contralateral breast cancer risk of 65% and ovarian cancer risk of 40%.) Older age and poorer prognosis from primary breast cancer further attenuate these gains.
Interventions to prevent second cancers, particularly PCM, may offer substantial LE gain for young women with BRCA-associated early-stage breast cancer. Estimates of LE gain may help women and their physicians consider the uncertainties, risks, and advantages of these interventions and lead to more informed choices about cancer prevention strategies.
Risk factors for contralateral breast cancer (CBC) may indicate a benefit for contralateral prophylactic mastectomy (CPM) at the time of unilateral mastectomy for breast cancer. The purpose of this study is to evaluate the efficacy of CPM in preventing CBC.
sixty-four patients undergoing CPM and a control group of 182 patients not undergoing CPM and matched for age, stage, surgery, chemotherapy, and hormonal therapy were retrospectively compared for CBC rate, disease-free survival, and overall survival.
Thirty-six CBCs occurred in the control group. In the CPM group, 3 CBCs were found at the time of prophylactic mastectomy, but none occurred subsequently (P = 0.005). Disease-free survival at 15 years in the CPM group was 55% (95% confidence interval [CI] 38% to 69%) versus 28% (95% CI 19% to 36%) in the control group (P = 0.01). Overall survival at 15 years was 64% (95% CI 45% to 78%) CPM versus 48% (95% CI 39% to 58%) in controls (P = 0.26).
CPM prevented CBC and significantly prolonged disease-free survival. Future studies will need to address risk assessment and contralateral breast cancer prevention in patients treated for early breast cancer.
To estimate the efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.
We followed the course of 745 women with a first breast cancer and a family history of breast and/or ovarian cancer who underwent contralateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. Family history information and cancer follow-up information were obtained from the medical record, a study-specific questionnaire, and telephone follow-up. Life-tables for contralateral breast cancers, which consider age at first breast cancer, current age, and type of family history, were used to calculate the number of breast cancers expected in our cohort had they not had a prophylactic mastectomy.
Of the 745 women in our cohort, 388 were premenopausal (age < 50 years) and 357 were post- menopausal. Eight women developed a contralateral breast cancer. Six events were observed among the premenopausal women, compared with 106.2 predicted, resulting in a risk reduction of 94.4% (95% confidence interval [CI], 87.7% to 97.9%). For the 357 postmenopausal women, 50.3 contralateral breast cancers were predicted, whereas only two were observed, representing a 96.0% risk reduction (95% CI, 85.6% to 99.5%).
The incidence of contralateral breast cancer seems to be reduced significantly after contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.
This trial was prompted by uncertainty about the need for breast irradiation after lumpectomy in node-negative women with invasive breast cancers of </= 1 cm, by speculation that tamoxifen (TAM) might be as or more effective than radiation therapy (XRT) in reducing the rate of ipsilateral breast tumor recurrence (IBTR) in such women, and by the thesis that both modalities might be more effective than either alone.
After lumpectomy, 1,009 women were randomly assigned to TAM (n = 336), XRT and placebo (n = 336), or XRT and TAM (n = 337). Rates of IBTR, distant recurrence, and contralateral breast cancer (CBC) were among the end points for analysis. Cumulative incidence of IBTR and of CBC was computed accounting for competing risks. Results with two-sided P values of.05 or less were statistically significant.
XRT and placebo resulted in a 49% lower hazard rate of IBTR than did TAM alone; XRT and TAM resulted in a 63% lower rate than did XRT and placebo. When compared with TAM alone, XRT plus TAM resulted in an 81% reduction in hazard rate of IBTR. Cumulative incidence of IBTR through 8 years was 16.5% with TAM, 9.3% with XRT and placebo, and 2.8% with XRT and TAM. XRT reduced IBTR below the level achieved with TAM alone, regardless of estrogen receptor (ER) status. Distant treatment failures were infrequent and not significantly different among the groups (P =.28). When TAM-treated women were compared with those who received XRT and placebo, there was a significant reduction in CBC (hazard ratio, 0.45; 95% confidence interval, 0.21 to 0.95; P =.039). Survival in the three groups was 93%, 94%, and 93%, respectively (P =.93).
In women with tumors </= 1 cm, IBTR occurs with enough frequency after lumpectomy to justify considering XRT, regardless of tumor ER status, and TAM plus XRT when tumors are ER positive.
To estimate the risk of contralateral breast cancer in BRCA1 and BRCA2 carriers after diagnosis and to determine which factors are predictive of the risk of a second primary breast cancer.
Patients included 491 women with stage I or stage II breast cancer, for whom a BRCA1 or BRCA2 mutation had been identified in the family. Patients were followed from the initial diagnosis of cancer until contralateral mastectomy, contralateral breast cancer, death, or last follow-up.
The actuarial risk of contralateral breast cancer was 29.5% at 10 years. Factors that were predictive of a reduced risk were the presence of a BRCA2 mutation (v BRCA1 mutation; hazard ratio [HR], 0.73; 95% CI, 0.47 to 1.15); age 50 years or older at first diagnosis (v <or= 49 years; HR, 0.63; 95% CI, 0.36 to 1.10); use of tamoxifen (HR, 0.59; 95% CI, 0.35 to 1.01); and history of oophorectomy (HR, 0.44; 95% CI, 0.21 to 0.91). The effect of oophorectomy was particularly strong in women first diagnosed prior to age 49 years (HR, 0.24; 95% CI, 0.07 to 0.77). For women who did not have an oophorectomy or take tamoxifen, the 10-year risk of contralateral cancer was 43.4% for BRCA1 carriers and 34.6% for BRCA2 carriers.
The risk of contralateral breast cancer in women with a BRCA mutation is approximately 40% at 10 years, and is reduced in women who take tamoxifen or who undergo an oophorectomy.
Women with unilateral breast carcinoma are at increased risk for developing contralateral breast carcinoma (CBC). The authors sought to identify predictors of malignant or moderate to high-risk histologic findings in contralateral prophylactic mastectomy (CPM) specimens, and to determine the efficacy of CPM.
The authors performed a retrospective review of 239 patients with unilateral early-stage breast carcinoma who underwent CPM. The number of CBCs expected if the contralateral breast had been left intact was calculated based on CBC rates observed in the Surveillance, Epidemiology, and End Results (SEER) database and on life-table analysis by family history.
In the current study, 11 patients (4.6%) had occult contralateral malignancies (4 invasive carcinomas and 7 ductal carcinomas in situ) and 44 (18.4%) patients had moderate to high-risk pathology (8 lobular carcinoma in situ, 11 atypical lobular hyperplasia, 25 atypical ductal hyperplasia). At 1846 patient-years of follow-up, only 1 patient (0.4%) developed a new CBC compared with 11 expected cancers based on SEER data. One CBC was observed among 140 patients with a family history of breast carcinoma, compared with 16 expected cancers based on life-table analysis adjusted for adjuvant therapy. The determinants of significant findings at CPM were invasive lobular histology, estrogen and progesterone receptor positivity, additional ipsilateral moderate to high-risk pathology, and age > 40 years at cancer diagnosis.
CPM was associated with a low risk of subsequent development of breast carcinoma. Evaluation of histologic findings in the ipsilateral breast may help to predict the likelihood of significant disease in the contralateral breast and assist in risk stratification.
Surgically removing both breasts to prevent breast cancer (bilateral prophylactic mastectomy or BPM) may reduce the incidence of breast cancer and improve survival in women with high breast cancer risk, but the studies have methodological limitations. After BPM, most are satisfied with their decision, but less satisfied with cosmetic results and body image. Many required additional surgeries. Most experience reduced cancer worry, but because women may overestimate their breast cancer risk, they need to understand their true risk if considering BPM. In women who have had cancer in one breast (and thus are at higher risk of developing a primary cancer in the other) removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival.
Locoregional failure after breast-conserving surgery is associated with increased risk of distant disease and death. The magnitude of this risk in patients receiving chemotherapy has not been adequately characterized.
Our study population included 2,669 women randomly assigned onto five National Surgical Adjuvant Breast and Bowel Project node-positive protocols (B-15, B-16, B-18, B-22, and B-25), who were treated with lumpectomy, whole-breast irradiation, and adjuvant systemic therapy. Cumulative incidences of ipsilateral breast tumor recurrence (IBTR) and other locoregional recurrence (oLRR) were calculated. Kaplan-Meier curves were used to estimate distant-disease-free survival (DDFS) and overall survival (OS) after IBTR or oLRR. Cox models were used to model survival using clinical and pathologic factors jointly with IBTR or oLRR as time-varying predictors.
Four hundred twenty-four patients (15.9%) experienced locoregional failure; 259 (9.7%) experienced IBTR, and 165 (6.2%) experienced oLRR. The 10-year cumulative incidence of IBTR and oLRR was 8.7% and 6.0%, respectively. Most locoregional failures occurred within 5 years (62.2% for IBTR and 80.6% for oLRR). Age, tumor size, and estrogen receptor status were significantly associated with IBTR. Nodal status and estrogen and progesterone receptor status were significantly associated with oLRR. The 5-year DDFS rates after IBTR and oLRR were 51.4% and 18.8%, respectively. The 5-year OS rates after IBTR and oLRR were 59.9% and 24.1%, respectively. Hazard ratios for mortality associated with IBTR and oLRR were 2.58 (95% CI, 2.11 to 3.15) and 5.85 (95% CI, 4.80 to 7.13), respectively.
Node-positive breast cancer patients who developed IBTR or oLRR had significantly poorer prognoses than patients who did not experience these events.
The routine use of sentinel node biopsy (SLNB) at the time of prophylactic mastectomy remains controversial. This retrospective study was undertaken to determine if SLNB is justified in patients undergoing CPM.
Between 1999 and 2004, 155 patients underwent contralateral prophylactic mastectomy (CPM) at the Magee-Womens Hospital of University of Pittsburgh Medical Center. Eighty patients (51.6%) had SLNB performed at the time of CPM. The therapeutic mastectomy and the CPM specimens were evaluated for histopathology. Goldflam's classification was used to determine the risk of malignancy in the CPM specimens.
Pathology in the therapeutic mastectomy specimens included 105 (68%) invasive carcinomas and 50 (32%) in-situ carcinomas. Multicentricity and/or multifocality were reported in 49.7%, and 70% were estrogen receptor positive. Two invasive breast cancers and three cases of DCIS were diagnosed in 155 CPM specimens (n = 5, 3.2%). The median number of SLN identified was 2 (range 1-6) from the CPM axilla. Two patients had positive SLNB for metastatic carcinoma (n = 2/80, 2.5%) with no primary tumor identified in the prophylactic mastectomy specimen. In both patients the therapeutic mastectomy was for recurrent invasive carcinoma in patients with a prior history of axillary node dissection. Occult carcinoma was found in five prophylactic mastectomy specimens: two invasive and three DCIS. Only 1 out of the 75 patients not undergoing SLNB at the time of their initial surgery would have required axillary staging for a previously undiagnosed invasive cancer in the CPM specimen on final pathology. Of all 155 patients undergoing CPM, only 4 (2.5%) had identified final pathologic findings where axillary staging with SLNB was beneficial. There was no evidence of arm lymphedema in any patient who had undergone CPM and SLNB at a median follow-up of 24 months.
Although SLNB is a minimally invasive method of axillary staging, this retrospective study does not support its routine use in patients undergoing CPM.
Many patients with unilateral breast cancer choose contralateral prophylactic mastectomy to prevent cancer in the opposite breast. The purpose of our study was to determine the use and trends of contralateral prophylactic mastectomy in the United States.
We used the Surveillance, Epidemiology and End Results database to review the treatment of patients with unilateral breast cancer diagnosed from 1998 through 2003. We determined the rate of contralateral prophylactic mastectomy as a proportion of all surgically treated patients and as a proportion of all mastectomies.
We identified 152,755 patients with stage I, II, or III breast cancer; 4,969 patients chose contralateral prophylactic mastectomy. The rate was 3.3% for all surgically treated patients; 7.7%, for patients undergoing mastectomy. The overall rate significantly increased from 1.8% in 1998 to 4.5% in 2003. Likewise, the contralateral prophylactic mastectomy rate for patients undergoing mastectomy significantly increased from 4.2% in 1998 to 11.0% in 2003. These increased rates applied to all cancer stages and continued to the end of our study period. Young patient age, non-Hispanic white race, lobular histology, and previous cancer diagnosis were associated with significantly higher rates. Large tumor size was associated with a higher overall rate, but with a lower rate for patients undergoing mastectomy.
The use of contralateral prophylactic mastectomy in the United States more than doubled within the recent 6-year period of our study. Prospective studies are needed to understand the decision-making processes that have led to more aggressive breast cancer surgery.
Patients with unilateral breast cancer are at increased risk of developing a second cancer in the contralateral breast. Some women choose contralateral prophylactic mastectomy (CPM) to prevent cancer in the contralateral breast. Several studies have demonstrated that CPM significantly decreases the occurrence of contralateral breast cancer. However, the effectiveness of CPM at reducing breast cancer mortality is not as clear. Moreover, CPM is not risk free and patients may need to undergo additional surgical procedures, especially if reconstruction is performed. Nevertheless, most patients are satisfied with their decision to undergo CPM. Alternatives to CPM include close surveillance with clinical breast examination, mammography and possibly breast magnetic resonance imaging. Endocrine therapy with tamoxifen or aromatase inhibitors significantly reduces the risk of contralateral breast cancer and may be more acceptable than CPM for some patients. The decision to undergo CPM is complex and many factors likely contribute to its use. Future prospective studies are critically needed to evaluate the decision-making processes leading to CPM.
Little data exist on whether efficacy benefits or side-effects persist after 5 years of adjuvant treatment with an aromatase inhibitor. We aimed to study long-term outcomes in the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial that compares anastrozole with tamoxifen after a median follow-up of 100 months.
We analysed postmenopausal women with localised invasive breast cancer. The primary endpoint disease-free survival (DFS), and the secondary endpoints time to recurrence (TTR), incidence of new contralateral breast cancer (CLBC), time to distant recurrence (TTDR), overall survival (OS), and death after recurrence were assessed in the total population (intention to treat; ITT: anastrozole, n=3125; tamoxifen, n=3116; total 6241) and the hormone-receptor-positive subpopulation, the clinically important subgroup for which endocrine treatment is now known to be effective (84% of ITT: anastrozole, n=2618; tamoxifen, n=2598; total 5216). After treatment completion, fractures and serious adverse events continued to be collected blindly (safety population: anastrozole, n=3092; tamoxifen, n=3094; total 6186). This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN18233230.
At a median follow-up of 100 months (range 0-126), DFS, TTR, TTDR, and CLBC were improved significantly in the ITT and hormone-receptor-positive populations. For hormone-receptor-positive patients: DFS hazard ratio (HR) 0.85 (95% CI 0.76-0.94), p=0.003; TTR HR 0.76 (0.67-0.87), p=0.0001; TTDR HR 0.84 (0.72-0.97), p=0.022; and CLBC HR 0.60 (0.42-0.85), p=0.004. Absolute differences in time to recurrence increased over time (TTR 2.8% [anastrozole 9.7%vs tamoxifen 12.5%] at 5 years and 4.8% [anastrozole 17.0%vs tamoxifen 21.8%] at 9 years) and recurrence rates remained significantly lower on anastrozole compared with tamoxifen after treatment completion (HR 0.75 [0.61-0.94], p=0.01). The fewer deaths after recurrence (anastrozole 245 vs tamoxifen 269) was not significant (HR 0.90 [0.75-1.07], p=0.2), and no effect was noted for OS (anastrozole 472 vs tamoxifen 477) HR 0.97 [0.86-1.11], p=0.7). Fracture rates were higher in patients receiving anastrozole than in those receiving tamoxifen during active treatment (number [annual rate]: 375 [2.93%] vs 234 [1.90%]; incidence rate ratio [IRR] 1.55 [1.31-1.83], p<0.0001), but were not different after treatment was completed (off treatment: 146 [1.56%] vs 143 [1.51%]; IRR 1.03 [0.81-1.31], p=0.79). We did not note any significant difference in risk of cardiovascular morbidity or mortality between anastrozole and tamoxifen treatment groups.
These data show long-term safety findings and establish clearly the long-term efficacy of anastrozole compared with tamoxifen as initial adjuvant treatment for postmenopausal women with hormone-sensitive, early breast cancer, and provide statistically significant evidence of a larger carryover effect after 5 years of adjuvant treatment with anastrozole compared with tamoxifen.
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