BRCA Mutations in the Young, High-Risk Female Population: Genetic Testing, Management of Prophylactic Therapies, and Implications for Plastic Surgeons

Ethical frameworks of informed consent in the age of pediatric precision medicine

Precision medicine is an emergent medical paradigm that uses information technology to inform the use of targeted therapies and treatments. One of the first steps of precision medicine involves acquiring the patient's informed consent to protect their rights to autonomous medical decision-making. In pediatrics, there exists mixed recommendations and guidelines of consent-related practices designed to safeguard pediatric patient interests while protecting their autonomy. Here, we provide a high-level, clinical primer of (1) ethical informed consent frameworks widely used in clinical practice and (2) promising modern adaptations to improve informed consent practices in pediatric precision medicine. Given the rapid scientific advances and adoption of precision medicine, we highlight the dual need to both consider the clinical implementation of consent in pediatric precision medicine workflows as well as build rapport with pediatric patients and their substitute decision-makers working alongside interdisciplinary health teams.

Staged Mastopexy before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Breast Reconstruction

BACKGROUND

Breast reconstruction following nipple-sparing mastectomy (NSM) in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes.

METHODS

A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before NSM and reconstruction in the authors' institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded.

RESULTS

In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3%) were reconstructed with free abdominal flaps, six (7.1%) with tissue expanders, and 66 (78.6%) with permanent subpectoral implants and acellular dermal matrix. There was one case of postoperative superficial nipple-areola complex epidermolysis (1.2%), and two cases of partial mastectomy skin flap necrosis (2.4%). The mean follow-up time after completion of reconstruction was 8.3 months.

CONCLUSION

Mastopexy or breast reduction before NSM and reconstruction is a safe procedure with a low risk of ischemic complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy

Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-term data on its efficacy in prevention of breast cancer. The objective of this study was to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years.

Methods

Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate.

Results

Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort.

Conclusions

The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.

Factors Associated With Increased Complications in Patients With BRCA Gene Mutations Undergoing Reconstructive Breast Surgery

Reconstructive breast surgery after bilateral prophylactic mastectomy in patients who carry a mutation of the breast cancer (BRCA) gene has been increasing. Undergoing risk-reducing breast surgery can be of great benefit to young patients who have a high risk of developing breast cancer. There is little available evidence about the rate of complications in these patients and which factors are related to increased complications. The objective of this study was to identify predictors of complications in BRCA gene mutation carriers who underwent reconstructive breast surgery. A single-center, retrospective cohort study was conducted that included all patients with a mutation of the BRCA gene who underwent a breast reconstructive procedure, either immediate or delayed, between January 2013 and March 2019 and received a minimum of 6 months' follow-up. The results of our study showed that smoking is the most important modifiable risk factor associated with an increased complication rate for reconstructive breast surgery in patients with BRCA gene mutation. Smoking cessation will reduce the patient's risk for postoperative complications by 50%; therefore, it should be encouraged in all surgical patients and enforced in patients undergoing prophylactic procedures.

CDH1 variants leading to gastric cancer risk management decision-making experiences in emerging adults: 'I am not ready yet'

Pathogenic/likely pathogenic variants (PLPV) in CDH1 are associated with a significantly increased lifetime risk for diffuse gastric cancer, with an average age of onset of 47 years. CDH1 PLPV carriers are recommended to have prophylactic total gastrectomy (PTG) or routine endoscopy surveillance. Emerging adults (EAs) may have unique circumstances that affect their medical management decision-making about PTG versus endoscopy. The study aim was to use qualitative interpretative phenomenological analysis method to understand the lived experience and medical management decision-making process for EAs carrying a CDH1 PLPV. Eligible participants were unaffected CDH1 PLPV carriers, ages 18 to 29, who had not undergone PTG and had discussed CDH1 medical management with a health provider. Semi-structured telephone interviews were transcribed verbatim and analyzed for major themes. Results show EAs wanted to avoid developing diffuse gastric cancer, but most do not feel they are ready for PTG. They had worries about PTG related to their identity exploration, financial stability, and careers. Most did not want to pass the PLPV to their children; however, the cost of preimplantation genetic testing with in vitro fertilization was a concern. Family medical history and self-understanding of endoscopy and PTG highly influenced medical management decision-making. Understanding of diffuse gastric cancer detection rate using endoscopy was inconsistent among participants. Body image was not a concern for most, but they worry about dietary restrictions after PTG. Lastly, connection to peers having the same experience was important. These findings increase our understanding of the medical management decision-making challenges for EA CDH1 carriers. EAs may take an extended time to decide what option is right for them. Thus, genetic counseling for CDH1 PLPV EA carriers requires long-term support and education.

Oncologic Considerations for Safe Gender-Affirming Mastectomy: Preoperative Imaging, Pathologic Evaluation, Counseling, and Long-Term Screening

SUMMARY

There remain significant gaps in the evidence-based care of patients undergoing gender-affirming mastectomy with regard to implications for breast cancer development and screening. The current clinical evidence does not demonstrate an increased risk of breast cancer secondary to testosterone therapy in transgender patients. Gender-affirmation mastectomy techniques vary significantly with regard to the amount of residual breast tissue left behind, which has unknown implications for the incidence of postoperative breast cancer and need for screening. Subcutaneous mastectomy should aim to remove all gross breast parenchyma, although this is limited in certain techniques. Tissue specimens should also be routinely sent for pathologic analysis. Several cases of incidental breast cancer after subcutaneous mastectomy have been described. There is little evidence on the need for or types of postoperative cancer screening. Chest awareness is an important concept for patients that have undergone subcutaneous mastectomies, as clinical examination remains the most common reported method of postmastectomy malignancy detection. In patients with greater known retained breast tissue, such as those with circumareolar or pedicled techniques, consideration may be given to alternative imaging modalities, although the efficacy and cost-utility of these techniques must still be proven. Preoperative patient counseling on the risk of breast cancer after gender-affirming mastectomy in addition to the unknown implications of residual breast tissue and long-term androgen exposure is critical. Patient awareness and education play an important role in shared decision-making, as further research is needed to define standards of medical and oncologic care in this population.

Analysis of Secondary Surgeries after Immediate Breast Reconstruction for Cancer Compared with Risk Reduction

Background:

This study sets out to compare reconstructive practice between patients undergoing immediate breast reconstruction (IBR) for cancer and those who opted for risk reduction (RR), with an emphasis on examining patterns of secondary surgery.

Methods:

Data collection was performed for patients undergoing mastectomy and IBR at a teaching hospital breast unit (2013–2016).

Results:

In total, 299 patients underwent IBR (76% cancer versus 24% RR). Implant-based IBR rate was similar in both groups (58% cancer versus 63% RR). Reconstruction loss (5.3% cancer versus 4.2% RR) and complication (16% cancer versus 12.9% RR) rates were similar. Cancer patients were more likely to undergo secondary surgery (68.4% versus 56.3%; P = 0.025), including contralateral symmetrization (22.8% versus 0%) and conversion to autologous reconstruction (5.7% versus 1.4%). Secondary surgeries were mostly planned for cancer patients (72% planned versus 28% unplanned), with rates unaffected by adjuvant therapies. This distribution was different in RR patients (51.3% planned versus 48.7% unplanned). The commonest secondary procedure was lipomodeling (19.7% cancer versus 23.9% RR). For cancer patients, complications resulted in a significantly higher unplanned secondary surgery rate (82.5% versus 38.8%; P = 0.001) than patients without complications. This was not evident in the RR patients, where complications did not lead to a significantly higher unplanned surgery rate (58.9% versus 35.2%; P = 0.086).

Conclusions:

Most of the secondary surgeries were planned for cancer patients. However, complications led to a significantly higher rate of unplanned secondary surgery. Approximately 1 in 4 RR patients received unplanned secondary surgery, which may be driven by the desire to achieve an optimal aesthetic outcome.

Complication rates among women undergoing preventive mastectomy: An Austrian registry

Germline variations in the BRCA-1 and BRCA-2 genes are associated with an increased risk of breast cancer. These variants are found in 5% of all breast cancer cases. Prophylactic mastectomy is the most effective risk-reducing method and shows high rates of patient satisfaction and acceptance. We established a registry of Austrian BRCA-1 and BRCA-2 mutation carriers who had undergone mastectomy for oncologic or prophylactic reasons. Data were collected on the type of operation, complications, and type of reconstructive surgery for patients between 2014 and 2017. The complication rate in patients with nipple-sparing mastectomy was significantly lower (23.1%) than in those with other types of mastectomies (60.7%; P = .005). In patients with implant-based breast reconstruction, subpectoral placement was associated with a significantly higher rate of complications than prepectoral placement (P = .025). Median implant volume was 350 cc (range: 155-650 cc), and a 100-cc increase was associated with doubling of the odds of a complication (regression coefficient = 0.007); based on this finding, some surgeons may decide on using smaller implants. In summary, we identified significant associations between the risk of complications and surgical characteristics, and found host factors like diabetes, BMI, and smoking among Austrian patients with BRCA-1 and BRCA-2 variants.

Sexual Health in the Era of Cancer Genetic Testing: A Systematic Review

INTRODUCTION

Genetic testing for germline cancer mutations allows individuals to gain specific knowledge of their hereditary cancer risks. Although risk-reducing strategies such as increased screening, prophylactic surgeries, and chemoprevention may be potentially lifesaving, these options can also significantly impact sexual health and function.

AIM

This study overviews current challenges at the intersection of cancer genetic testing and sexual health and describes a systematic review that summarizes this evidence, identifies methodological limitations, and provides future research directions.

METHODS

Articles on the intersection of genetic testing and/or family history of cancer, cancer risk, and sexual health were searched in Medline, PsycINFO, and PsycARTICLES databases.

MAIN OUTCOME MEASURE

The main outcome measure was sexual health in women who pursued risk-reducing surgery.

RESULTS

On the basis of the inclusion criteria, 32 studies were reviewed. 31 contained empiric data from 3,367 participants; one was a conceptual study. All studies were published between 2000 and 2019. Mean ages ranged from 38 to 51.2.

CONCLUSION

Given the prevalence of sexual dysfunction after risk-reducing surgery, evidence-based interventions are needed. Furthermore, quality of life that includes sexual health, in at-risk women who pursue preventive surgery, remains an understudied aspect of cancer genetic testing. Yusufov M, Bober SL. Sexual Health in the Era of Cancer Genetic Testing: A Systematic Review. Sex Med Rev 2020;8:231-241.

Should free deep inferior epigastric artery perforator flaps be considered a quality indicator in breast reconstruction?

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.

Are young women ready for BRCA testing? Comparing attitudes and comprehension of two age groups of healthy Italian women

BACKGROUND

Mutations in the BRCA 1/2 genes increase the risk of developing breast and/or ovarian cancer compared with the general population. However, the risk is low at age 30, and for women younger than 25, no preventive or screening options are available. Scientists wonder whether genetic predictive BRCA testing is appropriate at a very young age. Furthermore, although young women have positive attitudes toward testing, their understanding of genetic information seems scarce.

OBJECTIVE

To assess how young (18-24) versus adult (30-45) women at general population- level risk understand information about BRCA testing.

METHODS

302 women read an informative pamphlet and answered an ad-hoc questionnaire assessing usefulness of the information for decision making, intention to undergo predictive testing, and comprehension (perceived, general, and risk comprehension; open-ended questions).

RESULTS

Younger women had a lower comprehension of important BRCA information; it was more difficult for young women to identify the risk figures of cancer, and they showed errors when answering open-ended questions.

LIMITATIONS

Results are limited by the study's hypothetical nature.

CONCLUSIONS

Young women seem to have particular difficulty understanding BRCA information.

PRACTICE IMPLICATIONS

Counsellors should be aware of the difficulties young women have in understanding information about BRCA predictive testing.