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Abstract
Breast surgical oncology is a rapidly evolving field with significant advances shaped by practice-changing research. Three areas of ongoing controversy are (1) high rates of contralateral prophylactic mastectomy (CPM) in the United States despite uncertain benefit, (2) indications for and use of neoadjuvant chemotherapy (NACT) and endocrine therapy (NET), and (3) staging and treatment of the axilla, particularly after neoadjuvant systemic therapy. We discuss the patient populations for whom CPM may or may not be beneficial, indications for NACT and NET, and the trend toward de-escalation of locoregional axillary treatment.
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Affiliation(s)
- Lily Gutnik
- Duke University School of Medicine, DUMC 3513, Durham, NC 27707, USA. https://twitter.com/LGutnik
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Greener JR, Bass SB, Alhajji M, Gordon TF. Prospective assessment of contralateral prophylactic mastectomy decision-making in women with average risk: an application of perceptual mapping. Transl Behav Med 2021; 11:143-152. [PMID: 31760428 DOI: 10.1093/tbm/ibz159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Women with early-stage unilateral breast cancer and no familial or genetic risk factors are increasingly electing contralateral prophylactic mastectomy (CPM), despite the lack of evidence demonstrating improved outcomes. To better understand and extend the literature focused on treatment decision-making, a survey was conducted among women with early-stage breast cancer and no associated risk factors, who were in the process of making a surgical decision. This prospective study sought to expand our understanding of the factors that influence patients' decision to have CPM, with the goal of providing healthcare providers with useful guidance in supporting breast cancer patients who are making treatment decisions. Data were collected for this prospective study through an internet survey. Results were analyzed using perceptual mapping, a technique that provides visual insight into the importance of specific variables to groups of women making different surgical decisions, not available through conventional analyses. Results suggest that women more likely to elect CPM demonstrate greater worry about breast cancer through experiences with others and feel the need to take control of their health through selection of the most aggressive treatment option. The information obtained offers guidance for the development of targeted intervention and counsel that will support patients' ability to make high quality, informed decisions.
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Affiliation(s)
- Judith R Greener
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Sarah B Bass
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Mohammad Alhajji
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Thomas F Gordon
- Department of Psychology, University of Massachusetts Lowell, Lowell, MA, USA
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Greener JR, Bass SB, Lepore SJ. Contralateral prophylactic mastectomy: A qualitative approach to exploring the decision making process. J Psychosoc Oncol 2018; 36:145-158. [DOI: 10.1080/07347332.2017.1395940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Judith R. Greener
- Department of Social and Behavioral Sciences, Temple University, College of Public Health, Philadelphia, PA, USA
| | - Sarah Bauerle Bass
- Department of Social and Behavioral Sciences, Associate Professor of Public Health, Director, Risk Communication Laboratory, Temple University, College of Public Health, Philadelphia, PA, USA
| | - Stephen J. Lepore
- Department of Social and Behavioral Sciences, Professor and Chair, Temple University, College of Public Health, Philadelphia, PA, USA
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Kantor O, Ajmani G, Wang CH, Datta A, Yao K. The Shifting Paradigm for Breast Cancer Surgery in Patients Undergoing Neoadjuvant Chemotherapy. Ann Surg Oncol 2017; 25:164-172. [PMID: 29127538 DOI: 10.1245/s10434-017-6217-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Surgical therapy for newly diagnosed breast cancer has changed over the past decade, but these trends have not been well documented in patients undergoing neoadjuvant therapy (NAC). METHODS In a retrospective cohort study of the National Cancer Database (NCDB), we selected 285,514 women with clinical stage I-III breast cancer who underwent NAC or adjuvant therapy (AC) from 2006 to 2014. Breast-conserving surgery (BCS), unilateral mastectomy (UM), and bilateral mastectomy (BM) rates were compared between patients undergoing NAC and AC. RESULTS Of 285,514 women, 68,850 (24.1%) underwent NAC. Of NAC patients, 18,158 (26.4%) underwent BM and 27,349 (39.7%) BCS compared with 31,886 (14.7%) and 120,626 (55.7%) AC patients, respectively. From 2006 to 2014, BM increased from 16.1 to 28.8% (p < 0.001) for NAC and from 7.4 to 17.5% (p < 0.001) for AC. After adjusting for patient, tumor, and facility factors, NAC patients were 1.50 times [odds ratio (OR) 1.50, confidence interval (CI) 1.42-1.51] more likely to undergo BM then AC patients. The difference in BM rates between patients receiving NAC versus AC varied significantly by cT classification. This difference was the greatest among cT1 tumors between NAC and AC (31.7 vs. 13.0%, p < 0.001), followed by cT2 tumors (24.1 vs. 16.6%, p < 0.001) and cT3 tumors (24.3 vs. 22.3%). CONCLUSIONS AND RELEVANCE More NAC patients are undergoing BM while fewer are undergoing BCS compared with patients undergoing AC. This trend is particularly striking for those patients with smaller tumors who would otherwise be candidates for BCS.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Gaurav Ajmani
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Chi-Hsiung Wang
- Research Institute, NorthShore University HealthSystem, Evanston, IL, USA
| | - Avisek Datta
- Research Institute, NorthShore University HealthSystem, Evanston, IL, USA
| | - Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA. .,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.
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Yao K, Belkora J, Bedrosian I, Rosenberg S, Sisco M, Barrera E, Kyrillios A, Tilburt J, Wang C, Rabbitt S, Pesce C, Simovic S, Winchester DJ, Sepucha K. Impact of an In-visit Decision Aid on Patient Knowledge about Contralateral Prophylactic Mastectomy: A Pilot Study. Ann Surg Oncol 2016; 24:91-99. [PMID: 27654108 DOI: 10.1245/s10434-016-5556-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies have reported that breast cancer patients have limited understanding about the oncologic outcomes following contralateral prophylactic mastectomy (CPM). We hypothesized that an in-visit decision aid (DA) would be associated with higher patient knowledge about the anticipated short and long term outcomes of CPM. METHODS We piloted a DA which used the SCOPED: (Situation, Choices, Objectives, People, Evaluation and Decision) framework. Knowledge, dichotomized as "low" (≤3 correct) versus "high" (≥4 correct), was assessed immediately after the visit by a 5 item survey. There were 97 DA patients (response rate 62.2 %) and 114 usual care (UC) patients (response rate 71.3 %). RESULTS Patient demographic factors were similar between the two groups. Twenty-one (21.7 %) patients in the DA group underwent CPM compared with 18 (15.8 %) in the UC group (p = 0.22). Mean and median knowledge levels were significantly higher in the DA group compared with the UC group for patients of all ages, tumor stage, race, family history, anxiety levels, worry about CBC, and surgery type. Eighty-six (78.9 %) of UC versus 35 (37.9 %) DA patients had low knowledge. Of patients who underwent CPM, 15 (83.3 %) in the UC cohort versus 5 (25.0 %) of DA patients had "low" knowledge. CONCLUSIONS Knowledge was higher in the DA group. The UC group had approximately three times the number of patients of the DA group who were at risk for making a poorly informed decision to have CPM. Future studies should assess the impact of increased knowledge on overall CPM rates.
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Affiliation(s)
- Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Jeff Belkora
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | | | | | - Mark Sisco
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Ermilo Barrera
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alexandra Kyrillios
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | | | - Chihsiung Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, USA
| | - Sarah Rabbitt
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Catherine Pesce
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Sandra Simovic
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - David J Winchester
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Karen Sepucha
- Massachusetts General Hospital, Health Decision Sciences Center, Boston, MA, USA
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Tracy MS, Rosenberg SM, Dominici L, Partridge AH. Contralateral prophylactic mastectomy in women with breast cancer: trends, predictors, and areas for future research. Breast Cancer Res Treat 2013; 140:447-52. [PMID: 23893127 DOI: 10.1007/s10549-013-2643-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 07/16/2013] [Indexed: 01/02/2023]
Abstract
Recent studies have revealed increasing rates of contralateral prophylactic mastectomy (CPM) among women with unilateral early stage breast cancer. This trend has raised concerns, given the lack of evidence for a survival benefit from CPM and the relatively low risk of contralateral breast cancer for most women in this setting. In this article, we review available data regarding the value of CPM, predictors, and outcomes related to CPM, and areas for future research and potential intervention.
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Affiliation(s)
- Michaela S Tracy
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Ave Boston, Boston, MA 02215, USA
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Morrow M, Winograd JM, Freer PE, Eichhorn JH. Case records of the Massachusetts General Hospital. Case 8-2013. A 48-year-old woman with carcinoma in situ of the breast. N Engl J Med 2013; 368:1046-53. [PMID: 23484832 DOI: 10.1056/nejmcpc1214221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
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Abstract
Attitudes regarding the appropriate extent of surgery for breast cancer and the effect of surgery on breast cancer-specific survival have varied over time. Failure to maintain local control is associated with decreased survival, but the extent of surgery necessary for local control has decreased as other treatment modalities, such as radiotherapy and systemic therapy, have become more widely used. Both endocrine therapy and chemotherapy considerably reduce rates of local recurrence in the breast, as well as the incidence of contralateral breast cancer, and as efficacy in reducing metastatic disease increases, so does the benefit in reducing local recurrence. The excellent rates of local control in the ACOSOG Z11 trial after elimination of axillary dissection in patients with positive sentinel nodes receiving whole-breast irradiation and systemic therapy are a model for reducing surgical morbidity in the era of multimodality therapy.
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Affiliation(s)
- Monica Morrow
- From the Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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