Current Status of Contralateral Prophylactic Mastectomy: Investigating Structural Racial Disparity

BACKGROUND

Contralateral prophylactic mastectomy (CPM) remains a personal decision, influenced by psychosocial factors, including cosmesis and peace of mind. Although use of CPM is disproportionately low among Black patients, the degree to which these disparities are driven by patient- vs hospital-level factors remains unknown.

STUDY DESIGN

Patients undergoing mastectomy for nonmetastatic ductal or lobular breast cancer were tabulated using the National Cancer Database from 2004 to 2020. The primary endpoint was receipt of CPM. Multivariable logistic regression models were constructed with interaction terms between Black-serving hospital (BSH) status and patient race to evaluate associations with CPM. Cox proportional hazard models were used to evaluate long-term survival.

RESULTS

Of 597,845 women studied, 70,911 (11.9%) were Black. After multivariable adjustment, Black race (adjusted odds ratio 0.65, 95% CI 0.64 to 0.67) and treatment at BSH (adjusted odds ratio 0.84, 95% CI 0.83 to 0.85) were independently linked to lower odds of CPM. Although predicted probability of CPM was universally lower at higher BSH, Black patients faced a steeper reduction compared with White patients. Receipt of CPM was linked to improved survival (hazard ratio [HR] 0.84, 95% CI 0.83 to 0.86), whereas Black race was associated with a greater HR of 10-year mortality (HR 1.14, 95% CI 1.12 to 1.17).

CONCLUSIONS

Hospitals serving a greater proportion of Black patients are less likely to use CPM, suggestive of disparities in access to CPM at the institutional level. Further research and education are needed to characterize surgeon-specific and institutional practices in patient counseling and shared decision-making that shape disparities in access to CPM.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks

Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.

Assessment of the effect of the American Society of Breast Surgery guidelines on contralateral prophylactic mastectomy rates for unilateral breast cancer

BACKGROUND

In July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer. We incorporated these into practice with structured patient counseling and aimed to assess the effect of this initiative on contralateral prophylactic mastectomy rates.

METHODS

We evaluated female patients with unilateral breast cancer undergoing mastectomy at our institution from January 2011 to November 2022. Variables associated with contralateral prophylactic mastectomy and trends over time were analyzed using the Wilcoxon rank sum test or χ2 analysis as appropriate.

RESULTS

Among 3,208 patients, (median age 54 years) 1,366 (43%) had a unilateral mastectomy, and 1,842 (57%) also had a concomitant contralateral prophylactic mastectomy. Across all patients, contralateral prophylactic mastectomy rates significantly decreased post-implementation from 2017 to 2019 (55%) vs 2015 to 2016 (62%) (P = .01) but increased from 2020 to 2022 (61%). Immediate breast reconstruction rate was 70% overall (81% with contralateral prophylactic mastectomy and 56% without contralateral prophylactic mastectomy, P < .001). Younger age, White race, mutation status, and earlier stage were also associated with contralateral prophylactic mastectomy. Genetic testing increased from 27% pre-guideline to 74% 2020 to 2022, as did the proportion of patients with a pathogenic variant (4% pre-guideline vs 11% from 2020-2022, P < .001), of whom 91% had a contralateral prophylactic mastectomy. Among tested patients without a pathogenic variant and patients not tested, contralateral prophylactic mastectomy rates declined from 78% to 67% and 48% to 38% pre -and post-guidelines, respectively, P < .001.

CONCLUSION

Implementation of specific patient counseling was effective in decreasing contralateral prophylactic mastectomy rates. While recognizing that patient choice plays a significant role in the decision for contralateral prophylactic mastectomy, further educational efforts are warranted to affect contralateral prophylactic mastectomy rates, particularly in the setting of negative genetic testing.

Examining Race and Patient-Reported Outcomes After Contralateral Prophylactic Mastectomy with Reconstruction

BACKGROUND

Little is known regarding racial differences in satisfaction and quality of life (QOL) after contralateral prophylactic mastectomy (CPM). In this study, we aim to characterize associations between race, and postoperative satisfaction and well-being, utilizing the validated BREAST-Q patient-reported outcome measure.

PATIENTS AND METHODS

Patients were eligible if they were diagnosed with stage 0-III unilateral breast cancer and underwent mastectomy with immediate reconstruction at our institution between 2016 and 2022. BREAST-Q surveys were administered in routine clinical care preoperatively and postoperatively to assess QOL. We assessed whether the relationship between race, and domains of satisfaction with breasts and psychosocial well-being differed by receipt of CPM compared with unilateral mastectomy at 6 months, 1 year, 2 years, and 3 years following reconstruction.

RESULTS

Of 3334 women, 2040 (61%) underwent unilateral mastectomy and 1294 (39%) underwent CPM. Compared with White and Asian women who received CPM, Black women who underwent CPM were more likely to have higher BMI (p < 0.001), undergo autologous reconstruction (p = 0.006), and receive postmastectomy radiation (PMRT) (p < 0.001). There was no association between race and domains of satisfaction of breasts or psychosocial well-being for women who underwent unilateral mastectomy (p = 0.6 and p > 0.9, respectively) or CPM (p = 0.8 and p = 0.9, respectively). PMRT was negatively associated with both satisfaction with breasts (p < 0.001) and psychosocial well-being (p = 0.007).

CONCLUSIONS

Differences in satisfaction with breasts and psychosocial well-being at 3-year follow-up were not associated with race but rather treatment variables, particularly the receipt of PMRT. Further investigations with a larger and more diverse population are needed to validate these findings.

Trends of incidence and mortality in metaplastic breast cancer and the effect of contralateral prophylactic mastectomy: A population-based study

INTRODUCTION

Metaplastic breast cancer (MBC) is considered rare and aggressive. We examined the epidemiology of and prognostic factors for MBC and investigated the effect of contralateral prophylactic mastectomy (CPM), because neither had been thoroughly examined previously.

METHODS

We obtained data from the Surveillance, Epidemiology, and End Results (SEER)-18(2000-2018) for epidemiological and survival analysis.

RESULTS

The age-adjusted incidence per 100,000 persons of MBC increased significantly from 0.12 to 0.35 [annual percent change (APC):2.95%, 95% confidence interval [CI], 1.73-4.19]. The incidence-based mortality increased from 0.01 to 0.12 (APC: 5.01%, 95% CI: 2.50-7.58). The incidence of MBC patients who underwent CPM significantly increased from 0.003 to 0.039 with an APC of 10.96% (95%CI, 7.26-14.78). Older patients and those with higher T classification were less likely to receive CPM. The multivariate Cox model showed that CPM was not an independent predictor of good prognosis for both overall survival (OS) and breast cancer-specific survival (BCSS) (pre-propensity score matching (PSM): OS: P = 0.331; BCSS: P = 0.462. post-PSM: OS: P = 0.916; BCSS: P = 0.967). Subgroup analysis showed that CPM still did not provide a survival benefit to any risk groups.

CONCLUSION

In this study, we demonstrated that the incidence and incidence-based mortality of MBC have increased over the past decades. Although the number of MBC patients who underwent CPM has significantly increased recently, CPM did not confer a survival benefit compared with unilateral mastectomy, indicating that the decision to undergo CPM should be considered carefully.

Patient-driven decisions and perceptions of the 'safest possible choice': insights from patient-provider conversations about how some breast cancer patients choose contralateral prophylactic mastectomy

OBJECTIVE

Observe patient-clinician communication to gain insight about the reasons underlying the choice of patients with unilateral breast cancer to undergo contralateral prophylactic mastectomy (CPM), despite lack of survival benefit, risk of harms, and cautions expressed by surgical guidelines and clinicians.

METHODS & MEASURES

WORDS is a prospective study that explored patient-clinician communication and patient decision making. Participants recorded clinical visits through a downloadable mobile application. We analyzed 44 recordings from 22 patients: 9 who chose CPM, 8 who considered CPM but decided against it, and 5 who never considered CPM. We used abductive analysis combined with constructivist grounded theory methods.

RESULTS

Decisions to undergo CPM are patient-driven and motivated by perceptions that CPM is the most aggressive, and therefore safest, treatment option available. These decisions are shaped not primarily by the content of conversations with clinicians, but by the history of cancer in patients' families, their own first-hand experiences with cancers among loved ones, fear for their children, and anxiety about cancer recurrence.

CONCLUSION

The perception that CPM is the safest, most aggressive option strongly influences patients, despite scientific evidence to the contrary. Future efforts to address high CPM rates should focus on patient-driven decision making and cancer-related fears.

Complication Rates in Therapeutic Versus Prophylactic Bilateral Mastectomies: Insights From a National Database

BACKGROUND

The "Jolie effect" and other media focus on prophylactic treatments have resulted in unilateral breast cancer patients increasingly undergoing contralateral prophylactic mastectomy. Little is known, however, regarding outcomes following therapeutic versus prophylactic mastectomy. In this study, we compared complication rates of unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (BM-TP) to patients undergoing bilateral prophylactic mastectomy (BM-P).

METHODS

The BM-TP and BM-P patients from 2015 to 2019 were identified in Optum Clinformatics DataMart. Six-month outcomes were assessed and included wound complications, infection, hematoma/seroma, breast pain, fat necrosis, flap failure, implant failure/removal, other flap/implant complications, and other complications. Multivariable regression models adjusted for age, residence, insurance, race, and Charlson Comorbidity Index score.

RESULTS

Of 9319 women, 7114 (76.3%) underwent BM-TP, and 2205 (23.7%) underwent BM-P. In multivariable analysis, BM-TP had higher odds of overall complications (adjusted odds ratio [aOR], 1.35; P < 0.0001), but no difference was observed among patients who had autologous ( P = 0.1448) or no breast reconstruction ( P = 0.1530). Higher odds of overall complications persisted even after controlling for radiation therapy (aOR, 1.25; P = 0.0048) and chemotherapy (aOR, 1.28; P = 0.0047), but not after controlling for lymph node surgery ( P = 0.7765).

CONCLUSION

The BM-TP (vs BM-P) patients face higher odds of overall complications but without any difference in certain reconstructive modalities or after controlling for lymph node surgery.

Trends in bilateral mastectomy rates among different racial backgrounds: A National Cancer Database study

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.

Rates of Bilateral Mastectomy in Patients With Early-Stage Breast Cancer

This cohort study builds on previous research from the National Cancer Database to assess whether rates of bilateral mastectomy continue to increase.

Contralateral Prophylactic Mastectomy among Women with Pathogenic Variants in BRCA1/2: Overall Survival, Racial, and Ethnic Differences

Background

Patients with unilateral breast cancer carrying pathogenic variants in BRCA1/2 have the option to undergo contralateral prophylactic mastectomy (CPM). However, differences in CPM use and survival outcomes following CPM are poorly understood in this high-risk population, in part due to a lack of data from contemporary clinical cohorts. The objective of this study was to evaluate post-CPM overall survival (OS) and related racial/ethnic differences in a contemporary clinical cohort.

Methods

We retrospectively reviewed the medical records of women with a personal history of unilateral breast cancer carrying pathogenic variants in BRCA1/2 who were diagnosed between 1996 and 2012. Genetic test results, self-reported demographic characteristics, and clinical factors were abstracted from electronic medical records.

Results

Of 144 BRCA-positive patients, the majority were White (79.2%, n = 114). Overall, 56.1% (n = 81) of all BRCA1/2 carriers chose to undergo CPM, with no racial/ethnic difference in CPM election (p = 0.78). Of 81 patients who underwent CPM, there is strong evidence of a difference in survival between the racial/ethnic groups, with White patients having the highest OS compared to non-White patients (p = 0.001). Of the 63 patients who did not undergo CPM, there is no racial/ethnic difference in overall survival (p = 0.61). In multivariable cox regression, adjusted for demographic and clinical characteristics, OS was significantly lower among non-Whites than in Whites (HR = 0.39, p = 0.04).

Conclusions

Evaluation of a contemporary clinical cohort of BRCA-positive women with unilateral breast cancer showed no racial/ethnic difference in CPM use, but there was a significant difference in post-CPM overall survival.

Analysis of a Trend Reversal in US Lumpectomy Rates From 2005 Through 2017 Using 3 Nationwide Data Sets

Importance

Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM).

Objective

To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets.

Design and Setting

Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM.

Results

A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period.

Conclusions

This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.

[Non-genetic indications for risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To determine the value of performing a risk-reducting mastectomy (RRM) in the absence of a deleterious variant of a breast cancer susceptibility gene, in 4 clinical situations at risk of breast cancer.

DESIGN

The CNGOF Commission of Senology, composed of 26 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The Commission of Senology adhered to the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted.

METHODS

The Commission of Senology considered 8 questions on 4 topics, focusing on histological, familial (no identified genetic abnormality), radiological (of unrecognized cancer), and radiation (history of Hodgkin's disease) risk. For each situation, it was determined whether performing RRM compared with surveillance would decrease the risk of developing breast cancer and/or increase survival.

RESULTS

The Commission of Senology synthesis and application of the GRADE method resulted in 11 recommendations, 6 with a high level of evidence (GRADE 1±) and 5 with a low level of evidence (GRADE 2±).

CONCLUSION

There was significant agreement among the Commission of Senology members on recommendations to improve practice for performing or not performing RRM in the clinical setting.

Contralateral breast cancer after curative-intent treatment for ductal carcinoma in situ: Rate and associated clinicopathological and imaging risk factors

PURPOSE

Patients who have ductal carcinoma in situ (DCIS) are undergoing bilateral mastectomy at increasing rates. One of the reasons is to minimize contralateral breast cancer (CBC) risk. The purpose of this study is to determine the rate of and risk factors associated with CBC in women treated for DCIS.

METHODS

A retrospective study was performed of women with DCIS at surgery from 2007 to 2014 who had at least five-year follow-up. Patient attributes, imaging findings, histopathology results, and surgical and long-term outcomes were collected. Features associated with a CBC were assessed with multivariable logistic regression models.

RESULTS

613 women (mean 56 years, range 30-87) with DCIS underwent breast-conserving surgery (BCS) (n = 426), unilateral mastectomy (n = 101), or bilateral mastectomy (n = 86), with mean follow-up of 7.9 years. Of the 527 women who had BCS or unilateral mastectomy, 7.4% (n = 39) developed a CBC (DCIS in 12 and invasive cancer in 27). 4.1% (5/122) of women treated with adjuvant endocrine therapy developed a CBC, compared to 8.4% (34/405) who were not treated (p = .11). Features associated with CBC risk were younger age at menarche (adjusted odds ratio [aOR] of 0.76, p = .03) and low nuclear grade of DCIS (aOR of 5.43 for grade 1 versus 3, p = .01).

CONCLUSION

In women treated for DCIS, the overall rate of CBC was low at 7.4%. Younger age at menarche and low nuclear grade of DCIS had significant associations with higher CBC risk.

Controversies in Breast Cancer Surgery

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.

Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States

BACKGROUND

Contralateral prophylactic mastectomy (CPM) is more common in the United States than the rest of the world. However, the benefit of this procedure is still under question in many breast cancer scenarios. CPM utilization in the United States is in part dependent on a patient's health insurance coverage of breast oncology surgery and any desired reconstruction. However, there are great discrepancies in the coverage provided by insurers.

METHODS

The authors conducted a cross-sectional analysis of insurance policies for a CPM in the setting of diagnosed breast cancer. One hundred companies were selected based on their state enrollment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted.

RESULTS

Of the 100 companies assessed, 36 (36%) had a policy for CPM. Within those, significantly more provided coverage than denied the procedure (72% vs. 25%, p < 0.0001), with the remainder providing case-by-case coverage. Eleven criteria were identified from preauthorized policies, the most common prerequisite was breast cancer diagnosis under 45 years old (n = 9, 35%). Most policies did not differentiate between gender in their policies (n = 25, 69%), but of those that did, 100% (n = 11) provided coverage for men and women, with 82% (n = 9) requiring further criteria from the female patients.

CONCLUSION

The coverage of CPM in the United States varies from complete denial to unrestricted approval. This may be due to conflicting reports in the literature as to the utility of the procedure. The decision to undergo this procedure must be taken with thoughtful consideration and the support of a multidisciplinary approach.

Understanding Stakeholder Preference for Contralateral Prophylactic Mastectomy: A Conjoint Analysis

BACKGROUND

Despite increasing numbers of women with unilateral breast cancer undergoing CPM, quantitative evidence of all stakeholder preferences regarding CPM is lacking, particularly for healthy volunteers. Conjoint analysis, a marketing tool, can be used to quantify tradeoffs surrounding CPM.

STUDY DESIGN

The objective of this study was to quantify preferences for aspects of contralateral prophylactic mastectomy (CPM) decision-making process among key stakeholders. Healthy volunteers, women with cancer (WwCa), surgical oncologists, and plastic surgeons were surveyed with the same conjoint simulation exercise. Respondents chose between either single (SM) or double (DM) mastectomy under varying recurrence and complication rates, surveillance, and symmetry conditions. Hierarchical Bayesian models calculated partworth utilities and importance scores.

RESULTS

Overall, 1,244 respondents participated. The top 3 important factors for all stakeholders were surgical complication rates after DM, type of surgery (SM vs DM) independent of other variables, and 10-year future contralateral cancer risk after SM. HV and surgeons placed greatest importance on high rates of surgical complications after DM. WwCa preferred DM, regardless of complication risk or low rates of a 10-year future cancer episode after SM. Surgical oncologists strongly preferred SM and were more accepting of future cancer risk of 3% or 10% than other stakeholders. Symmetry and need for surveillance were least important factors for all stakeholders.

CONCLUSIONS

The threshold of acceptability for future cancer episodes and risk tolerance for complications varies by stakeholder, with a profound influence upon WwCA. Current findings suggest room for improved provider and patient alignment through behavioral techniques, such as framing, meanwhile highlighting changes in risk perception after a breast cancer diagnosis.

Prospective assessment of contralateral prophylactic mastectomy decision-making in women with average risk: an application of perceptual mapping

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.

Nomogram Predicts the Role of Contralateral Prophylactic Mastectomy in Male Patients With Unilateral Breast Cancer Based on SEER Database: A Competing Risk Analysis

Background

Contralateral prophylactic mastectomy (CPM) in female breast cancer (FBC) is supported by multiple clinical studies and consensus guidelines, but knowledge of preventive contralateral mastectomy in male breast cancer (MaBC) is very limited and its benefits are still controversial.

Methods

A retrospective cohort study was enrolled with 4,405 MaBC patients who underwent unilateral mastectomy (UM) or CPM from the Surveillance, Epidemiology, and End Results (SEER) database from 1998 to 2015. A nomogram was built based on the corresponding parameters by competing risks regression to predict the 3-year, 5-year, and 8-year probabilities of BCSD (breast cancer-specific death). C-index and calibration curves were chosen for validation. Net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to estimate the nomogram’s clinical utility.

Results

A total of 4,197 patients received UM and 208 patients received CPM, with 63-months median follow-up. In the competing risks regression, six variables (surgery, marital status, T-stage, N-stage, histology, tumor grade) were significantly associated with BCSD. Based on these independent prognosis factors, a nomogram model was constructed. The C-index 0.75 (95%CI: 0.73-0.77) in the training cohort and 0.73 (95%CI: 0.71-0.74) in the internal validation group suggested robustness of the model. In addition, the calibration curves exhibited favorably. The NRI values (training cohort: 0.54 for 3-year, 0.55 for 5-year, and 0.49 for 8-year BCSD prediction; validation cohort: 0.51 for 3-year, 0.45 for 5-year, and 0.33 for 8-year BCSD prediction) and IDI values (training cohort: 0.02 for 3-year, 0.03 for 5-year, and 0.04 for 8-year BCSD prediction; validation cohort: 0.02 for 3-year, 0.04 for 5-year, and 0.04 for 8-year BCSD prediction) indicated that the model performed better than the AJCC criteria-based tumor staging alone.

Conclusions

The administration of CPM was associated with the decrease in risk of BCSD in patients with MaBC. The nomogram could provide a precise and personalized prediction of the cumulative risk in patients with MaBC after CPM.

Ductal Carcinoma in Situ in Young Women: Increasing Rates of Mastectomy and Variability in Endocrine Therapy Use

BACKGROUND

Young women with ductal carcinoma in situ (DCIS) represent a unique cohort given considerations for future risk reduction and treatment effects on fertility and quality of life. We evaluated national patterns of care in the treatment of young women and the impact of those treatments on overall survival (OS).

METHODS

Women younger than 50 years of age diagnosed with pure DCIS from 2004 to 2016 in the National Cancer Database (NCDB) were identified. Clinical, demographic, and choice of local therapy are summarized and trended over time. OS was analyzed using Cox proportional hazard models.

RESULTS

A total of 52,150 women were identified, and the most common surgical treatment was breast-conservation surgery (BCS; 59%). Bilateral mastectomy (BM) increased in frequency from 2004 to 2016 (11-27%; p < 0.001). In women < 40 years of age, BM (39%) surpassed BCS (35%) in 2010 with a continued upward trend. On multivariable analysis, no OS benefit of BM (hazard ratio [HR] 0.99, p = 0.90) or unilateral mastectomy (UM; HR 0.98, p = 0.80) was observed when compared with BCS + radiation therapy (RT). Inferior OS was seen with BCS, Black race, estrogen receptor (ER)-negative, and tumor ≥ 2.5 cm (p ≤ 0.006). In ER+ patients, there was a significant difference in endocrine therapy (ET) use between BM (11%), UM (33%), and BCS (28%) compared with BCS + RT (64%, p < 0.001).

CONCLUSION

The use of BM for DCIS is increasing in younger patients and now exceeds breast-conservation approaches in women < 40 years of age with no evidence of improved OS. Among ER+ patients, the rates of ET are lower in the BM, UM, and BCS-alone groups compared with BCS + RT.

Frequency of Contralateral Prophylactic Mastectomy in Breast Cancer Patients with a Negative BRCA1 and BRCA2 Rapid Genetic Test Result

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.

RESULTS

A 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.

Decreasing contralateral prophylactic mastectomy rates in average-risk women with unilateral breast cancer

BACKGROUND

Contralateral prophylactic mastectomy (CPM) is not recommended for average-risk women with breast cancer due to lack of evidence for survival benefit, yet recent studies demonstrate increasing CPM rates.

METHODS

We identified patients with breast cancer treated with unilateral mastectomy (UM) with or without CPM. Rates of malignancy in CPM specimens and factors in CPM rates were assessed.

RESULTS

From 2013 to 2017, 1353 patients had UM and 355 had CPM. Our institution's occult malignancy detection rate was 5.04%. CPM rates decreased from 31.6% to 17.3% (p < 0.001) over 5 years. Compared to patients receiving UM only, patients receiving CPMs had significantly higher reconstruction rates (p < 0.001), which did not significantly change over time (p = 0.551) and tended to be younger (p < 0.001).

CONCLUSIONS

Patients having UM have low risk of contralateral malignancy. CPM is associated with younger age and breast reconstruction, suggesting factors to identify for patient and provider education.

Neuromuscular compensation strategies adopted at the shoulder following bilateral subpectoral implant breast reconstruction

Immediate two-stage subpectoral implant breast reconstruction after mastectomy requires the surgical disinsertion of the sternocostal fiber region of the pectoralis major (PM). The disinsertion of the PM would need increased contributions from intact shoulder musculature to generate shoulder torques. This study aimed to identify neuromuscular compensation strategies adopted by subpectoral implant breast reconstruction patients using novel muscle synergy analyses. Fourteen patients treated bilaterally with subpectoral implant breast reconstruction (>2.5 years post-reconstruction) were compared to ten healthy controls. Surface electromyography was obtained from sixteen shoulder muscles as participants generated eight three-dimensional (3D) shoulder torques in five two-dimensional arm postures bilaterally. Non-negative matrix factorization revealed the muscle synergies utilized by each experimental group on the dominant and non-dominant limbs, and the normalized similarity index assessed group differences in overall synergy structure. Bilateral subpectoral implant patients exhibited similar shoulder strength to healthy controls on the dominant and non-dominant arms. Our results suggest that 3D shoulder torque is driven by three shoulder muscle synergies in both healthy participants and subpectoral implant patients. Two out of three synergies were more similar than is expected by chance between the groups on the non-dominant arm, whereas only one synergy is more similar than is expected by chance on the dominant arm. While bilateral shoulder strength is maintained following bilateral subpectoral implant breast reconstruction, a closer analysis of the muscle synergy patterns underlying 3D shoulder torque generation reveals that subpectoral implant patients adopt compensatory neuromuscular strategies only with the dominant arm.

Capsular contracture in the modern era: A multidisciplinary look at the incidence and risk factors after mastectomy and implant-based breast reconstruction

BACKGROUND

Capsular contracture causes pain, poor cosmesis, and reoperations. This study analyzes its incidence and risk factors in a more modern treatment era.

METHODS

Patients undergoing mastectomy with implant reconstruction from 2010 to 18 were reviewed. Univariate and multivariate analysis evaluated rates and risk factors for capsular contracture.

RESULTS

Among 451 patients, the majority underwent nipple-sparing mastectomy (262, 58.1%) with one-stage reconstruction (283, 62.7%) utilizing subpectoral implants (353, 77.4%) and acellular dermal matrix (354, 78.5%). Overall capsular contracture incidence was 9.8%; the rate after post-mastectomy radiation therapy (PMRT) was 18.7%, and 7.5% for patients without PMRT. Significant factors included neoadjuvant chemotherapy (P = 0.006), hematoma (P = 0.047), and PMRT (P = 0.001). Multivariate analysis showed that PMRT increased risk of capsular contracture (OR = 3.12, 95% CI 1.55-6.26, P = 0.001), and adjuvant chemotherapy was protective (OR = 0.289, 95% CI 0.114-0.731, P = 0.01).

CONCLUSIONS

Incidence of capsular contracture is lower than previously reported. Advancing therapeutic techniques may reduce the risk of this complication.

A comparative study for the rate of adverse outcomes in unilateral and bilateral abdominal flap breast reconstruction: A meta-analysis

BACKGROUND

Adverse outcomes after unilateral vs bilateral breast reconstruction involve an unknown level of risk that warrants thorough investigation.

METHODS

To address this research need, PubMed, Ovid, Medline, EMBASE, and Scopus databases were searched through systematically from January 1, 1990, to January 1, 2019 to retrieve the relevant studies on the risk of postoperative complications after unilateral vs bilateral abdominal flap breast reconstruction. According to the pre-designed inclusion criteria, available data were extracted from the relevant studies, and then analyzed comparatively in order to identify the relative risk (RR) and 95% confidence intervals (CI) applying either a random or a fixed effects model.

RESULTS

Eventually, 20 studies involving 8122 female subjects met the inclusion criteria. It was found that unilateral reconstruction involved a significantly higher risk of flap loss (RR: 1.56, 95% CI: 1.21-2.00; P < .05) and fat necrosis (RR: 1.60, 95% CI: 1.23-2.09; P < .05) compared to bilateral reconstruction, while bilateral reconstruction involved a greater risk of abdominal hernia/bulge (RR: 1.67, 95% CI: 1.25-2.24; P < .05). The risk was found to be higher following bilateral free transverse rectus abdominis myocutaneous (fTRAM) flaps in comparison with deep inferior epigastric perforator (DIEP) flaps (RR: 2.62, 95% CI: 1.33-5.15; P < .05).

CONCLUSION

The risk of postoperative flap complications in unilateral breast reconstruction is significantly higher than that in bilateral reconstruction. Contrarily, the abdominal complications were significantly higher in the bilateral group vs the unilateral group. Meanwhile, the risk of abdominal hernia/bulge complication after bilateral breast reconstruction was significantly higher with fTRAM vs DIEP. Therefore, DIEP flaps are recommended in priority for bilateral breast reconstruction, unless specifically contraindicated.

Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery

Importance

Overtreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer.

Objective

To evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation.

Evidence Review

A systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use.

Findings

Concordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes.

Conclusions and Relevance

This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.

Trends in Contralateral Prophylactic Mastectomy

INTRODUCTION

Many breast cancer patients remove their contralateral breast unaffected by cancer, commonly referred to as contralateral prophylactic mastectomy (CPM). CPM has been extensively studied and does not improve survival in patients without deleterious genetic mutation or lobular histology. Despite these limited indications, CPM rates have increased recently. We observed CPM trends in our county safety-net hospital.

METHODS

We performed a retrospective review of women treated for breast cancer who underwent bilateral mastectomy in our institution.

RESULTS

We analyzed 100 CPMs: 51% (n = 51) had bilateral breast MRI before CPM, 54% (n = 54) had genetic testing prior to CPM, and 56% (n = 30) had a deleterious genetic result. Another 12% (n = 12) had lobular histology as the primary determinant for CPM. Of patients without genetic mutation or lobular histology, 13% (n = 13) had suspicious MRI findings in the CPM side that drove the decision for CPM. Forty-seven percent (n = 47) had reconstructive surgery documented.

CONCLUSION

Only 42% (n = 42) of patients who underwent CPM had a documented justifiable medical reason. In the future, physician and patient education may decrease unindicated CPM. We also found that 13% of women without a medical indication chose CPM based on suspicious MRI findings, while only 8% of these MRI findings were malignant.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Contralateral prophylactic mastectomy in breast cancer: what to discuss with patients

Introduction: The contralateral prophylactic mastectomy (CPM) rate in the U.S. has been steadily increasing. This is of particular concern because many women who undergo this procedure are candidates for breast-conserving surgery.Areas covered: CPM's medical benefit is related to the risk of contralateral cancer development and whether CPM provides a survival benefit. Contralateral cancer rates have decreased, and CPM does not provide a survival benefit. Other potential benefits of the procedure may be improved quality of life; these data are reviewed. Research efforts have been undertaken to better understand the decision-making process of patients who consider, and ultimately undergo, this procedure.Expert opinion: Decisional traits, personal values, the desire for peace of mind, and the desire to obtain breast symmetry are important factors that drive a woman's decision to undergo CPM. Additionally, many patients lack the knowledge on how different types of breast surgery impact outcomes. To improve the shared decision-making process, a stepwise approach to address possible misconceptions, and clarify the real risks/benefits of this procedure should be utilized. A clear recommendation (for/against) should be made for every patient with newly diagnosed breast cancer who considers CPM. Communication tools to assist patients and surgeons in this process are sorely needed.

Axillary management for young women with breast cancer varies between patients electing breast-conservation therapy or mastectomy

PURPOSE

Axillary treatment strategies for the young woman with early-stage, clinically node-negative breast cancer undergoing upfront surgery found to have 1-3 positive sentinel lymph nodes (SLNs) differ significantly after BCT and mastectomy. Here we compare axillary lymph node dissection (ALND) and regional nodal irradiation (NRI) rates between women electing breast-conservation therapy (BCT) versus mastectomy.

METHODS

From 2010 to 2016, women age < 50 years with clinical T1-T2N0 breast cancer having upfront surgery and found to have a positive SLN were identified. ALND and/or NRI receipt were compared between groups.

RESULTS

192 women undergoing BCT and 165 undergoing mastectomy were identified (median age: 44 years). 5.2% (10/192) of women undergoing BCT had an ALND versus 87% (144/165) of women undergoing mastectomy (p < 0.01). NRI was given to 48% (78/165) of mastectomy patients compared to 30% (57/192) of BCT patients (p < 0.01). Of the 75 mastectomy patients with 1-2 total positive lymph nodes after completion ALND, 44% received NRI. Women undergoing mastectomy were significantly more likely to receive both ALND and NRI than women undergoing BCS (45% vs 6%, p < 0.01).

CONCLUSION

Young cT1-2N0 breast cancer patients found to have 1-3 SLN metastases received ALND, NRI, and combined ALND/NRI more frequently if they elected mastectomy over BCT. Use of both ALND and postmastectomy radiotherapy (PMRT) in this population could be reduced in the future by omitting ALND in patients for whom the need for PMRT is clear with the finding of 1-2 SLN metastases.

MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer: 2-Year Follow-up

Objective

The American College of Radiology Imaging Network Trial 6667 showed that MRI can detect cancer in the contralateral breast that is missed by mammography and clinical examination at the time of the initial breast cancer diagnosis, based on 1-year follow-up. This study is a continuation of the trial that evaluates the diagnostic accuracy of MRI for contralateral breast cancer after 2 years of follow-up.

Methods

In total, 969 women with a diagnosis of unilateral breast cancer and no clinical or imaging abnormalities in the contralateral breast underwent breast MRI. The cancer status of all participants was monitored for 2 years after the initial MRI. Follow-up included documentation of any clinical, imaging, or interventional procedures performed. A study participant was considered positive for cancer if she had a tissue diagnosis of in situ or invasive breast cancer in the contralateral breast within 730 days of her initial MRI.

Results

Three additional cancers were diagnosed in the study population in the second year of the trial. The diagnostic yield for MRI for the 2-year period was 3% (31/969). After 2 years of follow-up, breast MRI has a sensitivity of 86% and specificity of 88% for detection of contralateral breast cancer. Its negative predictive value was 99%, and its positive predictive value was 22%. These values did not change significantly from the 1-year data.

Conclusion

A negative contralateral breast MRI has a very high and reliable negative predictive value over 2 years, and, therefore, is helpful in managing and counseling patients during the period of initial diagnosis and early treatment.

Assessing the additional surgical risk of contralateral prophylactic mastectomy and immediate breast implant reconstruction

INTRODUCTION

There has been a sharp rise in the rate of contralateral prophylactic mastectomy over the last decade, despite the low incidence of new primary cancers predicted for the contralateral breast. This study compares the postoperative complication rates between the diseased breast treated with mastectomy and the contralateral breast that underwent prophylactic mastectomy, followed by immediate bilateral breast implant reconstruction. We hypothesized that there will be no difference in postoperative outcomes between prophylactic and diseased groups, as the surgical approach would be comparable.

METHODS

After IRB approval, a retrospective chart review identified consecutive unilateral breast cancer patients who underwent bilateral mastectomy and immediate breast reconstruction between May 2008 and May 2018 at a tertiary academic medical center. A paired sample t-test and a penalized logic regression model were constructed to identify relationships between breast laterality and outcomes.

RESULTS

A total of 1117 patients with unilateral breast cancer who underwent bilateral mastectomy and immediate breast implant reconstruction were identified. Rates of capsular contracture and infection were significantly greater in the diseased breast, while rates of revision were significantly greater in the contralateral prophylactic breast. There were no statistically significant differences between breasts in rates of explant, skin flap necrosis or hematoma. When adjusted for confounding variables, a higher infection rate was observed in the diseased breast.

CONCLUSION

This study detected significant differences in postoperative complication rates between the diseased and prophylactic breasts following bilateral mastectomy and immediate breast implant reconstruction. Postoperative complications occurred more frequently in the diseased breast compared with low rates of complications in the contralateral prophylactic breast. This information is helpful for preoperative decision making, as surgeons and patients carefully weigh the additional risks of contralateral prophylactic procedure.

Effect of decision-making resources on satisfaction with decision to undergo contralateral prophylactic mastectomy (CPM)

BACKGROUND

Rates of contralateral prophylactic mastectomy (CPM) are increasing, and there are many resources available to help patients with decision-making. We sought to determine how often these were used, and whether their use influenced satisfaction with decision to pursue CPM.

METHODS

CPM patients at a large academic institution were surveyed regarding factors associated with their CPM decision, and their satisfaction with the same.

RESULTS

Of 58 CPM patients approached to participate, 55 completed the survey with a mean SWD score of 4.85 (range 3.00-5.00). Partner opinion (47.3%), family opinion (45.5%), other cancer patients' experiences (38.2%), and informational websites (38.2%) were the most frequently cited resources used by CPM patients. On multivariate analysis, controlling for other factors affecting SWD, use of other cancer patients' experiences predicted above average SWD (p = 0.049).

CONCLUSION

Those who use other cancer patients' experiences to aid in their surgical decision-making enjoy a higher satisfaction with their decision.

Physician Knowledge of Breast Cancer Recurrence and Contralateral Breast Cancer Risk is Associated with Increased Recommendations for Contralateral Prophylactic Mastectomy: a Survey of Physicians at NAPBC-Accredited Centers

BACKGROUND

Physician recommendation for contralateral prophylactic mastectomy (CPM) has been shown to influence whether a patient chooses CPM. Few studies have explored physician knowledge about contralateral breast cancer (CBC) and local recurrence (LR) risk and whether knowledge is associated with recommendation for CPM.

METHODS

We conducted a cross-sectional survey of physicians at National Accreditation Program for Breast Centers-accredited breast centers across the USA. Physician knowledge levels of CBC and LR were assessed and correlated with recommendations for CPM.

RESULTS

A total of 2412 physicians were surveyed with a 51% response rate (n = 1226). The results showed that 66% had correct knowledge about CBC risk and 57% had correct knowledge about LR. Moreover, 634 had high knowledge, viz. 176 (55.4%) breast surgeons, 171 (58.0%) medical oncologists, 196 (62.0%) radiation oncologists, and 72 (29.9%) plastic surgeons (p < 0.01). Compared with high knowledge, low knowledge was associated with favoring insurance coverage for patients at average CBC risk (53.8% vs. 39.8%, p < 0.01). Low knowledge was also associated with feeling that CPM was indicated in patients with high recurrence anxiety (39.2% vs. 28.9%), young patients with estrogen receptor (ER)-negative cancer (25.3% vs. 18.5%), and patients with two first-degree relatives with breast cancer (40.0% vs. 32.3%) (all p < 0.01). Multivariable analysis found physician type [odds ratio (OR) 3.76 for surgeons] and low knowledge (OR 1.46) to be significant independent predictors of favoring insurance coverage for CPM in patients at average risk.

CONCLUSIONS

Physician knowledge about CBC and LR could be improved. Lower knowledge is associated with favorable physician recommendations for CPM. It is not clear whether improving physician knowledge will change recommendations for CPM.

Trends in contralateral prophylactic mastectomy rate according to clinicopathologic and socioeconomic status

Purpose

There has been an increasing trend in the use of contralateral prophylactic mastectomy (CPM) among women diagnosed with unilateral breast cancer or mutations in BRCA1 or BRCA2 to reduce the occurrence of contralateral breast cancer. This study aimed to examine trends in the CPM rate according to clinicopathologic and socioeconomic status at a single institution in Korea.

Methods

This study included 128 patients with mutations in BRCA1 or BRCA2. Patients were divided into a CPM group (n = 8) and a non-CPM group (n = 120) between May 2013 and March 2016. The main outcome variables, including epidemiology, clinical features, socioeconomic status, and tumor characteristics, were analyzed.

Results

A total of 8 CPMs were performed among 128 patients. All CPM patients were married. The proportion of professional working women was higher in the CPM group (P = 0.049). Most patients who underwent CPM graduated college, compared to less than a third of the non-CPM group (P = 0.013). The CPM group had a higher rate of visits to the Hereditary Breast and Ovarian Cancer (HBOC) clinic (P = 0.021). The risk-reducing salpingo-oophorectomy (RRSO) rate was significantly higher in the CPM group (P < 0.01).

Conclusion

CPM rates were significantly different according to socioeconomic status. The CPM rate tends to increase in highly educated and professional working women. The socioeconomic status of patients is an important factor in the decision to participate in the HBOC clinic and undergo CPM or RRSO.

Predictors of uptake of contralateral prophylactic mastectomy in women with nonhereditary breast cancer

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.

Exploring reasons for overuse of contralateral prophylactic mastectomy in Canada

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.

Striving to Do No Harm and Yet Respect Patient Autonomy: Plastic Surgeons' Perspectives of the Consultation for Breast Reconstruction with Women Who Have Early-Stage Breast Cancer

BACKGROUND

Rates of contralateral prophylactic mastectomy (CPM) have doubled over the last decade among women considered low risk for developing contralateral breast cancer. Despite the strong association between CPM and breast reconstruction, little is known about the clinical encounter between patients and plastic surgeons. A qualitative study was performed to understand how plastic surgeons describe their roles in the treatment decision-making process through their consultations with women who have unilateral early-stage breast cancer.

METHODS

Semi-structured interviews with Ontario plastic surgeons were conducted. An inductive and interpretive thematic approach was initially used to analyze the data. The four principles of biomedical ethics then served as the conceptual lens to interpret the findings.

RESULTS

The participants in this study were 18 plastic surgeons, and data saturation was reached. Four themes were identified: maintaining non-maleficence, supporting patient autonomy, delivering (un)equal health care, and providing care to enhance well-being. The ongoing push-pull between competing ethical principles was the overarching theme, specifically, striving to balance parallel responsibilities to do no harm while also respecting patients' rights to make their own healthcare decisions.

CONCLUSIONS

In this patient-centric climate, it is important to acknowledge that patients may value outcomes such as achieving greater peace of mind above other clinical factors and are willing to incur additional risks to achieve these goals. Shared decision-making will help to reveal the rationale underlying each individual's treatment choice, which in turn will allow physicians to appropriately weigh patient requests with the best available medical evidence when counseling women on decision-making for breast cancer care.

Trends in Unilateral and Contralateral Prophylactic Mastectomy Use in Ductal Carcinoma In Situ of the Breast: Patterns and Predictors

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.

The use of contralateral prophylactic mastectomy among elderly patients in the United States

PURPOSE

Previous studies have reported increased rates of contralateral prophylactic mastectomy (CPM) in the United States among women with unilateral breast cancer. These trends have primarily focused on younger breast cancer patients. Given the growing aging population in the United States, we sought to determine whether CPM use is also increasing in elderly patients.

METHODS

This population-based study identified patients in the surveillance epidemiology and end results (SEER) data. We determined the rate of CPM as a proportion of all surgically treated patients and as a proportion of all mastectomies. We compared the unadjusted CPM rates over the study period using the Cochrane-Armitage test for trend. We used a logistic regression model to test for the factors associated with CPM utilization.

RESULTS

We identified 261,281 patients ≥ 65 years who underwent surgical treatment for breast cancer. For all patients treated with surgery for invasive breast cancer, the use of CPM increased from 1 in 2004 to 3% in 2014 (200% increase). Among mastectomy patients, the use of CPM increased from 3 in 2004 to 7% in 2014 (133% increase). Young age, non-Hispanic white race, lobular histology, higher grade, increased stage, negative lymph node status, and recent year of diagnosis were significantly associated with increased CPM rates.

CONCLUSIONS

For elderly patients the use of CPM has continued to increase in the United States. These observations warrant concern in light of increasing evidence that CPM does not improve oncological outcomes and is associated with increased morbidity in older patients.

An Evaluation of the Choice for Contralateral Prophylactic Mastectomy and Patient Concerns About Recurrence in a Reconstructed Cohort

BACKGROUND

Rising contralateral prophylactic mastectomy rates are a subject of national concern. This study assessed (1) factors critical to patients when deciding on contralateral prophylactic mastectomy and (2) patients' quality of life related to concerns about recurrence after unilateral or bilateral breast reconstruction.

METHODS

Patients with stage 0 to III breast cancer who underwent unilateral mastectomy or contralateral prophylactic mastectomy and breast reconstruction at a single institution between 2000 and 2012 were identified. Demographic and clinical data were extracted by chart review. Women's fears about breast cancer recurrence were assessed using the Concerns About Recurrence Scale, and motivational factors for contralateral prophylactic mastectomy were identified using the Decisions for Contralateral Prophylactic Mastectomy Survey.

RESULTS

Survey responses were received from 157 patients (59%) who underwent unilateral reconstruction and 109 (41%) who underwent bilateral reconstruction. The top 3 reasons for choosing contralateral prophylactic mastectomy were (1) decreasing the risk of contralateral breast disease (97%), (2) peace of mind (96%), and (3) improved survival (93%). Women who chose contralateral prophylactic mastectomy reported significantly greater overall fear and worry compared with the unilateral group, specifically, greater fears of dying and worries about adequately fulfilling roles of daily life (P < 0.05).

CONCLUSIONS

Despite no proven survival benefit, women chose contralateral prophylactic mastectomy primarily to optimize oncologic outcomes. Among breast reconstruction patients, women who underwent contralateral prophylactic mastectomy had greater anxiety and overall fear of breast cancer recurrence compared with those who chose unilateral mastectomy. These findings are important to consider when counseling women contemplating contralateral prophylactic mastectomy.

Comparison of breast-conserving therapy vs mastectomy in women under age 40: National trends and potential survival implications

INTRODUCTION

Despite initial increased rates of breast-conserving therapy compared to mastectomy after 1990, mastectomy rates have increased in women under age 40 since 2000. Our study explores the demographic and survival implications of this trend.

METHODS

The National Cancer Database was used to study stage 1 breast cancer diagnosed in women under age 40 between 2004 and 2014. Demographic and clinical data were obtained. Multivariable regression and survival analyses were performed.

RESULTS

Of 11 859 patients under age 40, 57.2% underwent mastectomy (39.0% unilateral and 61.0% bilateral) rather than breast-conserving therapy (42.8%). The rate of mastectomy was significantly higher in 2014 compared to 2004 (43.6% in 2004 vs 62.4% in 2014; P < 0.001). The rate of bilateral mastectomy was significantly higher in 2014 compared to 2004 in contrast to unilateral mastectomy (31.7% in 2004 vs 73.0% in 2014; P < 0.001). Non-Hispanic Caucasian ethnicity and private insurance status were predictors of bilateral mastectomy (OR 2.06 [95% CI: 1.84-2.30], P < 0.001; OR 1.39 [95% CI: 1.21-1.59], P < 0.001). Controlling for demographics, tumor grade, and adjuvant therapies, bilateral mastectomy was associated with significantly increased 10-year survival vs unilateral mastectomy (HR 0.75 [0.59-0.96], P = 0.023). Additionally, breast-conserving therapy was associated with significantly increased 10-year survival vs unilateral (HR 2.36 [95% CI: 1.83-3.05]; P < 0.001) and bilateral mastectomy (HR 2.30 [95% CI: 1.61-3.27]; P < 0.001).

CONCLUSIONS

The majority of women under age 40 with stage 1 invasive breast cancer underwent mastectomy instead of breast-conserving therapy. This largely reflects increased rates of contralateral prophylactic mastectomy. Bilateral mastectomy and breast-conserving therapy vs unilateral mastectomy were associated with a small but significant increase in survival. This finding warrants further investigation to determine the clinical implications of decision-making in younger women.

Social Network, Surgeon, and Media Influence on the Decision to Undergo Contralateral Prophylactic Mastectomy

OBJECTIVES

The rate of contralateral prophylactic mastectomy (CPM) has risen sharply in the past decade. The current study was designed to examine social network, surgeon, and media influence on patients' CPM decision-making, examining not only who influenced the decision, and to what extent, but also the type of influence exerted.

METHODS

Patients (N=113) who underwent CPM at 4 Indiana University-affiliated hospitals between 2008 and 2012 completed structured telephone interviews in 2013. Questions addressed the involvement and influence of the social network (family, friends, and nonsurgeon health professionals), surgeon, and media on the CPM decision.

RESULTS

Spouses, children, family, friends, and health professionals were reported as exerting a meaningful degree of influence on patients' decisions, largely in ways that were positive or neutral toward CPM. Most surgeons were regarded as providing options rather than encouraging or discouraging CPM. Media influence was present, but limited.

CONCLUSIONS

Patients who choose CPM do so with influence and support from members of their social networks. Reversing the increasing choice of CPM will require educating these influential others, which can be accomplished by encouraging patients to include them in clinical consultations, and by providing patients with educational materials that can be shared with their social networks. Surgeons need to be perceived as having an opinion, specifically that CPM should be reserved for those patients for whom it is medically indicated.

Active Participation in Decision-Making in Contralateral Prophylactic Mastectomy for Patients With Breast Cancer

BACKGROUND

We sought to determine how patient-physician communication affects patients' decision-making when choosing between contralateral prophylactic mastectomy (CPM) and unilateral mastectomy (UM).

METHODS

atients with breast cancer who underwent mastectomy at our institution were approached with a survey regarding patient-physician communication in CPM.

RESULTS

Of 101 patients who completed the survey, 55 underwent CPM (54.5%). Thirty-three patients (33%) stated that their physician recommended UM, six (6%) stated their physician recommended CPM, and 61 (61%) stated they engaged in active participation in decision-making. Most patients whose doctors recommended UM chose UM (78.8%); similarly, 83.3% of those whose doctors recommended CPM chose CPM. Of 39 patients whose doctors recommended a particular surgical option, eight (20.5%) did not follow their doctor's advice. These patients were equally as satisfied with their decisions as those who followed their doctor's advice (P = 0.441). Patients engaging in active participation in decision-making tended to choose CPM (68.3% versus 30.8%, P < 0.001). Patients who did not engage in active participation were similarly satisfied with their decision as those who did (P = 0.286). Twelve patients (12%) stated they preferred their doctor to provide a recommendation, seven (7%) preferred to make the decision on their own, and 81 (81%) preferred to actively participate in their decision-making with the physician.

CONCLUSIONS

Patients tend to follow physicians' recommendation of UM or CPM; patients engaging in SDM tend to choose CPM. Most patients prefer to engage in active participation in decision-making with their physician but were equally satisfied with their surgical decision whether they engaged in active participation or not.

Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study

Background

Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm.

Methods

A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions.

Results

The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da.

Conclusions

The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.