Rate of contralateral prophylactic mastectomy is influenced by preoperative MRI recommendations

Breast MRI for Extent of Disease: Association of Demographic Factors and Biopsy Compliance on Surgical Decisions in Patients with BI-RADS 4 and 5 Findings

BACKGROUND

The decision to pursue bilateral mastectomy without pathological confirmation of additional preoperative MRI lesions is likely multifactorial. We investigated the association of demographic factors and biopsy compliance following preoperative breast MRI with changes in surgical management in patients with newly diagnosed breast cancer.

METHODS

A retrospective review of BI-RADS 4 and 5 MRIs performed across a health system from March 2018 to November 2021 for assessment of disease extent and preoperative planning. Patient characteristics, including demographics, Tyrer-Cuzick risk score, pathology from index cancer and biopsy of MRI findings, and pre- and post-MRI surgical plans were recorded. Analysis compared patients who underwent biopsy with those who did not.

RESULTS

The final cohort included 323 patients who underwent a biopsy and 89 who did not. Of patients who underwent a biopsy, 144/323 (44.6%) had additional cancer diagnoses. MRI did not change management in 179/323 patients (55.4%) who underwent biopsy and in 44/89 patients (51.7%) who did not. Patients with a biopsy were more likely to have additional breast conservation surgery (P < .001) and patients without a biopsy were more likely to have a change in management to bilateral mastectomy P = .009). Patients without a biopsy who underwent a management change to bilateral mastectomy were significantly younger (47.2 vs 58.6; P < .001) and more likely to be white (P = .02) compared to those choosing bilateral mastectomy after biopsy.

DISCUSSION

Biopsy compliance is associated with changes in surgical decisions, and younger, white women are more likely to pursue aggressive surgical management without definitive pathologic diagnoses.

Abbreviated MRI for Preoperative Assessment of Breast Cancer: is Maximal Intensity Projection (MIP) of the First Post Contrast Acquisition Subtracted (Fast) Sequence Sufficient for Disease Evaluation?

Objectives

The aim of this study was to assess the diagnostic performance of abbreviated MRI (AMRI) using the maximal intensity projection (MIP) reconstruction of the first post-contrast acquisition subtracted (FAST) compared with MIP+FAST and full-protocol MRI (fpMRI) for the preoperative assessment of breast cancer (BC) in a biopsy-proven cancer population.

Methods

In this monocentric retrospective study, two readers consensually assessed two AMRI protocols consisting of MIP reconstruction of the FAST (MIP) and MIP+FAST. 228 patients were included with a breast MRI performed between 2013 and 2014, 207 of them (90.8%) had biopsy-proven cancer with 256 lesions. Data of MIP and MIP+FAST were compared to full-protocol MRI (fpMRI) reading and to the reference standard including 6-month follow-up imaging and pathology as the reference.

Results

MIP, MIP+FAST and fpMRI demonstrated a per-lesion sensitivity for BC detection of 87.5% (224/256, 95%CI: 82.9-91.3%) and 97.7% (250/256, 95-99.1%) and 98.4% (252/256, 96.1-99.6%), respectively with a statistical difference between MIP compared to MIP+FAST and fpMRI when considering confidence intervals. Per-lesion specificity was not different [MIP: 47.6% (10/21, 25.7-70.2%), MIP+FAST: 52.4% (11/21,29.8-74.3%, fpMRI: 66.7% (14/21, 43-85.4%)].

Conclusion

AMRI using only MIP is not accurate for the pre-operative assessment of BC due to lower sensitivity when compared to MIP+FAST and fpMRI. AMRI using the MIP+FAST acquisition in the preoperative setting seems promising as it could be used as the same protocol for both screening and staging in case of positive cases, without need for a recall fpMRI. This needs confirmation with cohort including higher rate of negative cases in order to evaluate the specificity.

The Influence of Patient Exposure to Breast Reconstruction Approaches and Education on Patient Choices in Breast Cancer Treatment

BACKGROUND

The landscape of surgical and medical management and patient choices for breast cancer treatment changes as breast reconstruction and oncoplastic approaches improve and diversify. Increased access to breast reconstruction, in addition to patient education, influences the breast cancer patient. Therefore, the examination of the possible impact of reconstructive surgery on all stages of the breast cancer management per se seemed timely.

METHODS

Plastic surgery consults were arranged for 520 new patients diagnosed with breast cancer (2012-2016) including patients with noninvasive breast cancer but at high risk of further cancer development. To test the plastic surgery impact on patient choices regarding the management of the cancer, a subset of 90 patients was identified to test the plastic surgery impact on patient choices. These patients were referred to plastic surgery, following the first round of consultations by surgical and medical oncologists with only the preliminary oncological management plan defined. After a plastic surgery consultation, but prior to finalization of the overall oncological management plan, they were surveyed on the subject of modification of their personal choices and requests pertaining to their cancer management.

RESULTS

In this subset of 90 patients 40 (44%) returned to their surgical or medical oncologist considering changes of the primary management plan after their plastic surgery consultation. Twenty-six (28%) ultimately altered their plan, and the following patient-driven changes were made: mastectomy as opposed to lumpectomy (18 patients [20%]), contralateral prophylactic mastectomy (11 patients [12%]), nipple/areola removal as opposed to nipple/areola sparing suggested by the oncologists (5 patients [6%]), oncoplastic breast reduction as part of lumpectomy (5 patients [6%]), and other modifications (3 patients [3%]).

CONCLUSIONS

Decisions for altering the preliminary oncologic plan or choosing a specific alternative (eg, lumpectomy plus radiation vs mastectomy) resulted from patient education on (1) reconstructive options, (2) aesthetic pitfalls and results. and (3) their interfacing with the oncological outcomes. Ultimately, plastic surgeons influence the multispecialty breast cancer management and patient decision-making process. Therefore, oncological literacy for plastic surgeons is essential to provide state-of-the-art breast cancer care and avoidance of suboptimal patient decisions.

Parental Status in Treatment Decision Making among Women with Nonmetastatic Breast Cancer

Background. Having dependent children may affect cancer treatment decisions. We sought to describe women's surgery and chemotherapy decisions in nonmetastatic breast cancer by parental status. Methods. We conducted a secondary analysis of the 2015 cross-sectional Share Thoughts on Breast Cancer Study, conducted in 7 Midwestern states in the United States, restricted to women of prime parenting age (aged 20-50 years) who consented to the use of their medical records (N = 225). We examined treatment decisions using data visualization and logistic regression (adjusted for age, stage, family history of breast cancer, income, education, race, health insurance, and partner status). Results. Women with dependent children received bilateral mastectomy more often than women without dependent children (adjusted odds ratio 3.09, 95% confidence interval 1.44-6.62).We found no differences in the receipt of chemotherapy by parental status. Women reported more active roles in surgery than in chemotherapy decision making. Conclusions. As a likely factor in cancer treatment decisions, parental status should be addressed in clinical practice and research. Future research should assess patients' sense of ownership in treatment decision making by treatment type.

Contralateral prophylactic mastectomy rate and predictive factors among patients with breast cancer who underwent multigene panel testing for hereditary cancer

Although multigene panel testing is increasingly common in patients with cancer, the relationship between its use among breast cancer patients with non-BRCA mutations or variants of uncertain significance (VUS) and disease management decisions has not been well described. This study evaluated the rate and predictive factors of CPM patients who underwent multigene panel testing. Three hundred and fourteen patients with breast cancer who underwent multigene panel testing between 2014 and 2017 were included in the analysis. Of the 314 patients, 70 elected CPM. Election of CPM by gene status was as follows: BRCA carriers (42.3%), non-BRCA carriers (30.1%), and VUS (10.6%). CPM election rates did not differ between non-BRCA carriers and BRCA carriers (P = 0.6205). Among non-BRCA carriers, negative hormone receptor status was associated with CPM (P = 0.0115). For those with a VUS, hormone receptor status was not associated with CPM (P = 0.1879). Although the rate of CPM between BRCA carriers and non-BRCA carriers was not significantly different, the predictors of CPM were different in each group. Our analyses shed the light on the increasing use of CPM among patients who are non-BRCA carriers as well those with a VUS. Our study elucidates the differing predictive factors of CPM election among BRCA carriers, non-BRCA carries, and those with a VUS. Our findings reveal the need for providers to be cognizant that non-BRCA genes and VUS drive women to elect CPM despite the lack of data for contralateral breast cancer risk associated with these genes.

Basic Findings Regarding Breast Cancer in Korea in 2015: Data from a Breast Cancer Registry

The Korean Breast Cancer Society (KBCS) has established a nationwide breast cancer database using an online registration program in 1996. The present study aimed to analyze the basic findings and trends of breast cancer in Korea in 2015 using the data provided by the Korea Central Cancer Registry and the KBCS. In 2015, a total of 22,550 patients were newly diagnosed with breast cancer, of which 3,331 were carcinoma in situ cases and 19,219 were invasive cancer cases. The incidence rate of breast cancer in Korea has steadily increased since the nationwide database was established, and the crude rate and age-standardized rate including that of carcinoma in situ, were 88.1 and 66.0 cases per 100,000 women, respectively. In terms of age, the incidence of breast cancer was the highest in the 40–49-year-old age group (7,889 patients, 35.0%). With regard to surgical procedure, breast-conserving surgery was frequently performed (62.3%). However, the rate of mastectomy has been gradually increasing since 2012, that is, from 32.3% in 2014 to 36.1% in 2015. The rate of early breast cancer has continued to increase, and that of stages III and IV breast cancer was only 9.1% at the time of diagnosis. However, the 5-year survival rate of patients with carcinoma in situ from 2011 to 2015 was 92.3%, which was 14.4% higher than that from 1993 to 1995 (77.9%). Analysis of data from the nationwide registry of breast cancer will not only help to understand the characteristics of breast cancer in individuals in Korea, but will also significantly contribute to the treatment and research of breast cancer. Therefore, a high quality database for breast cancer in Korea must be established by further initiating registration project and establishing an objective legal basis.

Relationship between preoperative breast MRI and surgical treatment of non-metastatic breast cancer

BACKGROUND AND OBJECTIVES

More extensive surgical treatments for early stage breast cancer are increasing. The patterns of preoperative MRI overall and by stage for this trend has not been well established.

METHODS

Using Breast Cancer Surveillance Consortium registry data from 2010 through 2014, we identified women with an incident non-metastatic breast cancer and determined use of preoperative MRI and initial surgical treatment (mastectomy, with or without contralateral prophylactic mastectomy (CPM), reconstruction, and breast conserving surgery ± radiation). Clinical and sociodemographic covariates were included in multivariable logistic regression models to estimate adjusted odds ratios and 95% confidence intervals.

RESULTS

Of the 13 097 women, 2217 (16.9%) had a preoperative MRI. Among the women with MRI, results indicated 32% higher odds of unilateral mastectomy compared to breast conserving surgery and of mastectomy with CPM compared to unilateral mastectomy. Women with preoperative MRI also had 56% higher odds of reconstruction.

CONCLUSION

Preoperative MRI in women with DCIS and early stage invasive breast cancer is associated with more frequent mastectomy, CPM, and reconstruction surgical treatment. Use of more extensive surgical treatment and reconstruction among women with DCIS and early stage invasive cancer whom undergo MRI warrants further investigation.

Surgical Management of Breast Cancer in 2010-2011 SEER Registries by Hormone and HER2 Receptor Status

BACKGROUND

Although locoregional recurrence is known to affect overall survival for operable breast cancer, the impact of receptor status on locoregional control is debated. Currently, hormone receptor (HR) and human epidermal growth factor receptor-2 (HER2) status are generally not considered relevant to surgical choice. This study examines recent population-level surgical trends with regard to receptor status.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) data to identify stage I-III female breast cancers diagnosed from 2010 to 2011. Patients were categorized by HR and HER2 receptor status. Univariate and multivariate logistic regressions were used to assess factors associated with undergoing mastectomy and the choice of contralateral prophylactic mastectomy (CPM).

RESULTS

The overall mastectomy rate for the 87,504 women diagnosed in 2010-2011 was 43.4 %. On multivariate analysis, the odds of receiving mastectomy was greater for HER2-positive disease with either HR-negative or HR-positive status, than for women with HER2-negative/HR-positive disease (odds ratio 1.73 and 1. 31, respectively; all p values <0.001). Age, stage, marital status, race, and year of diagnosis also correlated with mastectomy. Triple-negative breast cancer (TNBC) was associated with CPM, while HER2 status was not. The mastectomy rate, which increased overall from 2006 to 2010, has continued to increase for stage III disease but has decreased for stage I disease. Mastectomy rates overall were lower in 2011 than 2010 (p = 0.012).

CONCLUSIONS

HER2-positive disease and TNBC were independent predictors of more extensive surgery in this large, recent, population-based cohort. Although mastectomy rates have continued to increase for stage III disease, mastectomy rates overall were lower in 2011 than in previous years.