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Giannakeas V, Lim DW, Narod SA. Bilateral Mastectomy and Breast Cancer Mortality. JAMA Oncol 2024; 10:1228-1236. [PMID: 39052262 PMCID: PMC11273285 DOI: 10.1001/jamaoncol.2024.2212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/05/2024] [Indexed: 07/27/2024]
Abstract
Importance The benefit of bilateral mastectomy for women with unilateral breast cancer in terms of deaths from breast cancer has not been shown. Objectives To estimate the 20-year cumulative risk of breast cancer mortality among women with stage 0 to stage III unilateral breast cancer according to the type of initial surgery performed. Design, Settings, and Participants This cohort study used the Surveillance, Epidemiology, and End Results (SEER) Program registry database to identify women with unilateral breast cancer (invasive and ductal carcinoma in situ) who were diagnosed from 2000 to 2019. Three closely matched cohorts of equal size were generated using 1:1:1 matching according to surgical approach. The cohorts were followed up for 20 years for contralateral breast cancer and for breast cancer mortality. The analysis compared the 20-year cumulative risk of breast cancer mortality for women treated with lumpectomy vs unilateral mastectomy vs bilateral mastectomy. Data were analyzed from October 2023 to February 2024. Exposures Type of breast surgery performed (lumpectomy, unilateral mastectomy, or bilateral mastectomy). Main Outcomes and Measures Contralateral breast cancer or breast cancer mortality during the 20-year follow-up period among the groups treated with lumpectomy vs unilateral mastectomy vs bilateral mastectomy. Results The study sample included 661 270 women with unilateral breast cancer (mean [SD] age, 58.7 [11.3] years). After matching, there were 36 028 women in each of the 3 treatment groups. During the 20-year follow-up, there were 766 contralateral breast cancers observed in the lumpectomy group, 728 contralateral breast cancers in the unilateral mastectomy group, and 97 contralateral cancers in the bilateral mastectomy group. The 20-year risk of contralateral breast cancer was 6.9% (95% CI, 6.1%-7.9%) in the lumpectomy-unilateral mastectomy group. The cumulative breast cancer mortality was 32.1% at 15 years after developing a contralateral cancer and was 14.5% for those who did not develop a contralateral cancer (hazard ratio, 4.00; 95% CI, 3.52-4.54, using contralateral breast cancer as a time-dependent covariate). Deaths from breast cancer totaled 3077 women (8.54%) in the lumpectomy group, 3269 women (9.07%) in the unilateral mastectomy group, and 3062 women (8.50%) in the bilateral mastectomy group. Conclusions and Relevance This cohort study indicates that the risk of dying of breast cancer increases substantially after experiencing a contralateral breast cancer. Women with breast cancer treated with bilateral mastectomy had a greatly diminished risk of contralateral breast cancer; however, they experienced similar mortality rates as patients treated with lumpectomy or unilateral mastectomy.
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Affiliation(s)
- Vasily Giannakeas
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Women’s Age Lab, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - David W. Lim
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Surgery, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Steven A. Narod
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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2
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Hamid SA, Bakkila B, Schultz KS, Grimshaw AA, Gunderson CG, Godfrey EL, Lee C, Berger E, Rosenberg S, Greenup RA. "Peace of Mind" After Mastectomy: A Scoping Review. Ann Surg Oncol 2024; 31:5168-5179. [PMID: 38717543 DOI: 10.1245/s10434-024-15360-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/09/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Many women eligible for breast conservation therapy (BCT) elect unilateral mastectomy (UM) with or without contralateral prophylactic mastectomy (CPM) and cite a desire for "peace of mind." This study aimed to characterize how peace of mind is defined and measured and how it relates to surgical choice. METHODS Nine databases were searched for relevant articles through 8 October 2023, and data were extracted from articles meeting the inclusion criteria. RESULTS The inclusion criteria were met by 20 studies. Most were prospective cohort studies (65%, 13/20). In the majority of the studies (72%, 13/18), Non-Hispanic white/Caucasian women comprised 80 % or more of the study's sample. Almost half of the studies used the phrase "peace of mind" in their publication (45%, 9/20), and few directly defined the construct (15%, 3/20). Instead, words representing an absence of peace of mind were common, specifically, "anxiety" (85%, 17/20), "fear" (75%, 15/20), and "concern" (75%, 15/20). Most of the studies (90%, 18/20) measured peace of mind indirectly using questionnaires validated for anxiety, fear, worry, distress, or concern, which were administered at multiple postoperative time points (55%, 11/20). Most of the studies (95%, 18/19) reported at least one statistically significant result showing no difference in peace of mind between BCT, UM, and/or CPM at their latest time of assessment. CONCLUSION Peace of mind is largely framed around concepts that suggest its absence, namely, anxiety, fear, and concern. Existing literature suggests that peace of mind does not differ among average-risk women undergoing BCT, UM, or CPM. Shared surgical decisions should emphasize at least comparable emotional and/or psychosocial well-being between CPM and breast conservation.
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Affiliation(s)
- Safraz A Hamid
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
- Yale National Clinician Scholars Program, New Haven, CT, USA.
| | - Baylee Bakkila
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kurt S Schultz
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Yale Investigative Medicine Program, New Haven, CT, USA
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Craig G Gunderson
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Clara Lee
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth Berger
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Rachel A Greenup
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Huang H, Wei T, Zhang A, Zhang H, Kong L, Li Y, Li F. Comparison of Survival Outcomes in Young Patients With Breast Cancer Receiving Contralateral Prophylactic Mastectomy Versus Unilateral Mastectomy. Clin Breast Cancer 2023; 23:752-762.e7. [PMID: 37586925 DOI: 10.1016/j.clbc.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Contralateral prophylactic mastectomy (CPM) has been performed for several decades in patients with unilateral breast cancer (BC). However, the survival benefits of CPM are controversial, particularly in young women. MATERIALS AND METHOD In this retrospective study, the clinical total of 69,000 young female patients (age ≤ 40 years) who were diagnosed to have unilateral BC and underwent unilateral mastectomy (UM) or CPM between January 1, 2000 and December 31, 2019 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to minimize selection bias and overcome differences in tumor characteristics between the CPM and UM groups. Overall survival (OS) and BC-specific survival (BCSS) were assessed using Kaplan-Meier curves and compared across groups using log-rank test. Multivariable Cox proportional hazards regression analysis was performed to estimate hazard ratios (HRs). RESULTS A total of 36,528 patients (21,600 and 14,928 patients in the UM and CPM groups, respectively) were included in follow study. The CPM group showed a higher 5-year OS rate (82.1% vs. 75.8%) and a higher 5-year BCSS rate (83.5% vs. 77.7%) than the UM group. Multivariate Cox analysis after PSM (n = 13,089) showed that CPM significantly decreased 25% risk of all-cause mortality (OS, HR: 0.75, 95% confidence interval [CI]: 0.70-0.80; P < .001) and 25% risk of BC-specific mortality (BCSS, HR: 0.75, 95% CI: 0.70-0.80; P < .001) in young BC patients as compared to UM. CONCLUSION This study suggests that CPM improved OS and BCSS benefits in young BC patients as compared to UM. Randomized clinical trials with a larger sample size are required in the future to confirm these results.
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Affiliation(s)
- Hongbo Huang
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tingting Wei
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Aijie Zhang
- Department of Health Management Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Heng Zhang
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lingquan Kong
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunhai Li
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Fan Li
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Oztas B, Ugurlu M, Kurt G. Fear of cancer recurrence and coping attitudes of breast cancer survivors. Eur J Cancer Care (Engl) 2022; 31:e13742. [PMID: 36259514 DOI: 10.1111/ecc.13742] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 09/09/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to determine the fear of cancer recurrence levels and coping orientation of breast cancer survivors. METHODS This descriptive exploratory study was conducted using a web-based online survey. This article is written using the STROBE checklist. The study was completed with 204 women participants. Data were collected using the 'Demographic and Clinical Information Form', 'Fear of Cancer Recurrence Inventory (FCRI)' and 'Coping Orientation to Problems Experienced Inventory-Revised (COPE-R)'. RESULTS FCRI total score average within the scope of the study was calculated as 42.00 ± 18.88. Women's COPE-R total score average is 80.62 ± 13.20. There was a positive correlation between FCRI total score and COPE-R (r = 0.183, p = 0.009). According to the results of multiple linear regression analysis, age, education level, CAM usage, getting psychological support and COPE-R subscales (accommodation, avoidance, self-punishment) were associated with FCRI total score. CONCLUSIONS The fear of cancer recurrence experienced by breast cancer survivors was associated with their coping orientation. Determining the fear of cancer recurrence level and coping orientation of breast cancer survivors by healthcare professionals will guide the reduction of women's fear of cancer recurrence and further the development of adaptive coping orientation.
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Affiliation(s)
- Bediye Oztas
- Gulhane Faculty of Nursing, University of Health Sciences Turkey, Ankara, Turkey
| | - Meltem Ugurlu
- Gulhane Faculty of Health Sciences, Midwifery Department, University of Health Sciences Turkey, Ankara, Turkey
| | - Gonul Kurt
- Gulhane Faculty of Nursing, University of Health Sciences Turkey, Ankara, Turkey
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Giannakeas V, Lim DW, Narod SA. The risk of contralateral breast cancer: a SEER-based analysis. Br J Cancer 2021; 125:601-610. [PMID: 34040177 PMCID: PMC8368197 DOI: 10.1038/s41416-021-01417-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/26/2021] [Accepted: 04/22/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We sought to estimate the annual risk and 25-year cumulative risk of contralateral breast cancer among women with stage 0-III unilateral breast cancer. METHODS We identified 812,851 women with unilateral breast cancer diagnosed between 1990 and 2015 in the SEER database and followed them for contralateral breast cancer for up to 25 years. Women with a known bilateral mastectomy were excluded. We calculated the annual risk of contralateral breast cancer by age at diagnosis, by time since diagnosis and by current age. We compared risks by ductal carcinoma in situ (DCIS) versus invasive disease, by race and by oestrogen receptor (ER) status of the first cancer. RESULTS There were 25,958 cases of contralateral invasive breast cancer diagnosed (3.2% of all patients). The annual risk of contralateral breast cancer over the 25-year follow-up period was 0.37% and the 25-year actuarial risk of contralateral invasive breast cancer was 9.9%. The annual risk varied to a small degree by age of diagnosis, by time elapsed since diagnosis and by current age. The 25-year actuarial risk was similar for DCIS and invasive breast cancer patients (10.1 versus 9.9%). The 25-year actuarial risk was higher for black women (12.7%) than for white women (9.7%) and was lower for women with ER-positive breast cancer (9.5%) than for women with ER-negative breast cancer (11.2%). CONCLUSIONS Women with unilateral breast cancer experience an annual risk of contralateral breast cancer ~0.4% per year, which persists over the 25-year follow-up period.
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MESH Headings
- Adult
- Age Factors
- Aged
- Aged, 80 and over
- Breast Neoplasms/epidemiology
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Female
- Humans
- Middle Aged
- Neoplasm Staging
- Neoplasms, Second Primary/epidemiology
- Neoplasms, Second Primary/metabolism
- Neoplasms, Second Primary/pathology
- Receptors, Estrogen/metabolism
- Risk Factors
- SEER Program
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Affiliation(s)
- Vasily Giannakeas
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - David W Lim
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Lim DW, Metcalfe KA, Narod SA. Bilateral Mastectomy in Women With Unilateral Breast Cancer: A Review. JAMA Surg 2021; 156:569-576. [PMID: 33566074 DOI: 10.1001/jamasurg.2020.6664] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Rates of bilateral mastectomy continue to increase in average-risk women with unilateral in situ and invasive breast cancer. Contralateral prophylactic mastectomy rates increased from 5% to 12% of all operations for breast cancer in the US from 2004 to 2012. Among women having mastectomy, rates of contralateral prophylactic mastectomy have increased from less than 2% in 1998 to 30% in 2012. Observations The increased use of breast magnetic resonance imaging and genetic testing has marginally increased the number of candidates for bilateral mastectomy. Most bilateral mastectomies are performed on women who are at no special risk for contralateral cancer. The true risk of contralateral breast cancer is not associated with the decision for contralateral prophylactic mastectomy; rather, the clinical factors associated with the probability of distant recurrence are associated with bilateral mastectomy. Several changes in society and health care delivery appear to act concurrently and synergistically. First, the anxiety engendered by a fear of cancer recurrence is focused on the contralateral cancer because this is most easily conceptualized and provides a ready target that can be acted upon. Second, the modern woman with breast cancer is supported by the surgeon and the social community of breast cancer survivors. Surgeons want to respect patient autonomy, despite guidelines discouraging bilateral mastectomy, and most women have their expenses covered by a third-party payer. Satisfaction with the results is high, but the association with improved psychosocial well-being remains to be fully understood. Conclusions and Relevance Reducing the use of medically unnecessary contralateral prophylactic mastectomy in women with nonhereditary, unilateral breast cancer requires a social change that addresses patient-, physician-, cultural-, and systems-level enabling factors. Such a transformation begins with educating clinicians and patients. The concerns of women who want preventive contralateral mastectomy must be explored, and women need to be informed of the anticipated benefits (or lack thereof) and risks. Areas requiring further study are considered.
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Affiliation(s)
- David W Lim
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Kelly A Metcalfe
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Zheng Y, Li J, Hong C, Wu H, Lige W, Qi A, Guo J, Wang J, Zhu L, Li X, Zhang Y. Clinical features, prognosis, and influencing factors of contralateral prophylactic mastectomy in 58 patients with breast cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1665. [PMID: 33490177 PMCID: PMC7812232 DOI: 10.21037/atm-20-7780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The past two decades have witnessed the increasing application of contralateral prophylactic mastectomy (CPM) for women with breast cancer in the western countries. Over 30% of young patients choose to underwent CPM up to 2015. However, the adoption rate of CPM has not shown a remarkably increasing in Asian countries. In China, only a few centers have introduced CPM, and no relevant literature has been published. In this study, we look forward to identify the clinical features and prognostic factors of women who underwent CPM in our hospital, to inform decision-making processes for both doctors and patients. Methods The clinical data of 58 eligible patients were retrospectively analyzed. Intergroup comparisons were based on independent samples t-test and chi square test. The 5-year disease-free survival (DFS) and overall survival (OS) were obtained by using life tables, and factors affecting the survivals were analyzed by using the Kaplan-Meier method. Results The mean age of these women was 40.14±11.17 years, with 30 patients (51.7%) being ≤40 years; 13 patients (22.4%) had a family history of breast cancer; and 49 (69.0%) had known risk factors for breast cancer. The median follow-up period was 66.77 months, the 5-year OS was 89% and the 5-year DFS was 74%. The average age of onset was 41.53 (±10.964) in the disease-free survival group and 34.18 (±10.4) years in the recurrence/metastasis group, and t-test revealed a significant difference in the average age between these two groups (P=0.049). Chi-square test showed that the disease progression rate significantly differed among the different age subgroups and among subjects with different body mass index (BMI) (all P≤0.05). Moreover, surgical procedure, family history of breast cancer, and some other factors showed no significant correlation with disease progression (all P>0.05). Kaplan-Meier survival analysis and log rank test further confirmed the above findings. Conclusions The majority of patients who choose CPM are young and with known risk factors for breast cancer. Part of the young patients (≤40 years of age) are at a higher risk of disease progression.
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Affiliation(s)
- Yiqiong Zheng
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jie Li
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Chenyan Hong
- School of Medicine, Naikai University, Tianjin, China
| | - Huan Wu
- Big Data Center, PLA General Hospital, Beijing, China
| | - Wuri Lige
- Big Data Center, PLA General Hospital, Beijing, China
| | - Aiying Qi
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jin Guo
- Gaojing Clinic, Jingxi Unit, PLA General Hospital, Beijing, China
| | - Jiandong Wang
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Li Zhu
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiru Li
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yanjun Zhang
- Department of General Surgery, First Medical Center of the People's Liberation Army (PLA) General Hospital, Beijing, China
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Giardiello D, Kramer I, Hooning MJ, Hauptmann M, Lips EH, Sawyer E, Thompson AM, de Munck L, Siesling S, Wesseling J, Steyerberg EW, Schmidt MK. Contralateral breast cancer risk in patients with ductal carcinoma in situ and invasive breast cancer. NPJ Breast Cancer 2020; 6:60. [PMID: 33298933 PMCID: PMC7609533 DOI: 10.1038/s41523-020-00202-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/01/2020] [Indexed: 12/11/2022] Open
Abstract
We aimed to assess contralateral breast cancer (CBC) risk in patients with ductal carcinoma in situ (DCIS) compared with invasive breast cancer (BC). Women diagnosed with DCIS (N = 28,003) or stage I-III BC (N = 275,836) between 1989 and 2017 were identified from the nationwide Netherlands Cancer Registry. Cumulative incidences were estimated, accounting for competing risks, and hazard ratios (HRs) for metachronous invasive CBC. To evaluate effects of adjuvant systemic therapy and screening, separate analyses were performed for stage I BC without adjuvant systemic therapy and by mode of first BC detection. Multivariable models including clinico-pathological and treatment data were created to assess CBC risk prediction performance in DCIS patients. The 10-year cumulative incidence of invasive CBC was 4.8% for DCIS patients (CBC = 1334). Invasive CBC risk was higher in DCIS patients compared with invasive BC overall (HR = 1.10, 95% confidence interval (CI) = 1.04-1.17), and lower compared with stage I BC without adjuvant systemic therapy (HR = 0.87; 95% CI = 0.82-0.92). In patients diagnosed ≥2011, the HR for invasive CBC was 1.38 (95% CI = 1.35-1.68) after screen-detected DCIS compared with screen-detected invasive BC, and was 2.14 (95% CI = 1.46-3.13) when not screen-detected. The C-index was 0.52 (95% CI = 0.50-0.54) for invasive CBC prediction in DCIS patients. In conclusion, CBC risks are low overall. DCIS patients had a slightly higher risk of invasive CBC compared with invasive BC, likely explained by the risk-reducing effect of (neo)adjuvant systemic therapy among BC patients. For support of clinical decision making more information is needed to differentiate CBC risks among DCIS patients.
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Affiliation(s)
- Daniele Giardiello
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Iris Kramer
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Maartje J Hooning
- Department of Medical Oncology-Cancer Epidemiology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School, Neuruppin, Germany
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Elinor Sawyer
- School of Cancer & Pharmaceutical Sciences, Kings College London, London, UK
| | - Alastair M Thompson
- Department of Surgery, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, USA
| | - Linda de Munck
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
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Smith ME, Vitous CA, Hughes TM, Shubeck SP, Jagsi R, Dossett LA. Barriers and Facilitators to De-Implementation of the Choosing Wisely ® Guidelines for Low-Value Breast Cancer Surgery. Ann Surg Oncol 2020; 27:2653-2663. [PMID: 32124126 DOI: 10.1245/s10434-020-08285-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND To address overuse of unnecessary practices, several surgical organizations have participated in the Choosing Wisely® campaign and identified four breast cancer surgical procedures as unnecessary. Despite evidence demonstrating no survival benefit for all four, evidence suggests only two have been substantially de-implemented. Our objective was to understand why surgeons stop performing certain unnecessary cancer operations but not others and how best to de-implement entrenched and emerging unnecessary procedures. METHODS We sampled surgeons who treat breast cancer in a variety of practice types and geographic regions in the United States. Using a semi-structured guide, we conducted telephone interviews (n = 18) to elicit attitudes and understand practices relating to the four identified breast cancer procedures in the Choosing Wisely® campaign. Interviews were recorded, transcribed, and anonymized. Transcripts were analyzed using inductive and deductive thematic analysis. RESULTS For the two procedures successfully de-implemented, surgeons described a high level of confidence in the data supporting the recommendations. In contrast, surgeons frequently described a lack of familiarity or skepticism toward the recommendation to avoid sentinel-node biopsy in women ≥ 70 years of age and the influence of other collaborating oncology providers as justification for continued use. Regarding contralateral prophylactic mastectomy, surgeons consistently agreed with the recommendation that this was unnecessary, yet reported continued utilization due to the value placed on patient autonomy and preference. CONCLUSIONS With a growing focus on the elimination of ineffective, unproven or low value practices, it is imperative that the behavioral determinants are understood and targeted with specific interventions to decrease utilization rapidly.
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Affiliation(s)
- Margaret E Smith
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah P Shubeck
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
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Giardiello D, Steyerberg EW, Hauptmann M, Adank MA, Akdeniz D, Blomqvist C, Bojesen SE, Bolla MK, Brinkhuis M, Chang-Claude J, Czene K, Devilee P, Dunning AM, Easton DF, Eccles DM, Fasching PA, Figueroa J, Flyger H, García-Closas M, Haeberle L, Haiman CA, Hall P, Hamann U, Hopper JL, Jager A, Jakubowska A, Jung A, Keeman R, Kramer I, Lambrechts D, Le Marchand L, Lindblom A, Lubiński J, Manoochehri M, Mariani L, Nevanlinna H, Oldenburg HSA, Pelders S, Pharoah PDP, Shah M, Siesling S, Smit VTHBM, Southey MC, Tapper WJ, Tollenaar RAEM, van den Broek AJ, van Deurzen CHM, van Leeuwen FE, van Ongeval C, Van't Veer LJ, Wang Q, Wendt C, Westenend PJ, Hooning MJ, Schmidt MK. Prediction and clinical utility of a contralateral breast cancer risk model. Breast Cancer Res 2019; 21:144. [PMID: 31847907 PMCID: PMC6918633 DOI: 10.1186/s13058-019-1221-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Breast cancer survivors are at risk for contralateral breast cancer (CBC), with the consequent burden of further treatment and potentially less favorable prognosis. We aimed to develop and validate a CBC risk prediction model and evaluate its applicability for clinical decision-making. METHODS We included data of 132,756 invasive non-metastatic breast cancer patients from 20 studies with 4682 CBC events and a median follow-up of 8.8 years. We developed a multivariable Fine and Gray prediction model (PredictCBC-1A) including patient, primary tumor, and treatment characteristics and BRCA1/2 germline mutation status, accounting for the competing risks of death and distant metastasis. We also developed a model without BRCA1/2 mutation status (PredictCBC-1B) since this information was available for only 6% of patients and is routinely unavailable in the general breast cancer population. Prediction performance was evaluated using calibration and discrimination, calculated by a time-dependent area under the curve (AUC) at 5 and 10 years after diagnosis of primary breast cancer, and an internal-external cross-validation procedure. Decision curve analysis was performed to evaluate the net benefit of the model to quantify clinical utility. RESULTS In the multivariable model, BRCA1/2 germline mutation status, family history, and systemic adjuvant treatment showed the strongest associations with CBC risk. The AUC of PredictCBC-1A was 0.63 (95% prediction interval (PI) at 5 years, 0.52-0.74; at 10 years, 0.53-0.72). Calibration-in-the-large was -0.13 (95% PI: -1.62-1.37), and the calibration slope was 0.90 (95% PI: 0.73-1.08). The AUC of Predict-1B at 10 years was 0.59 (95% PI: 0.52-0.66); calibration was slightly lower. Decision curve analysis for preventive contralateral mastectomy showed potential clinical utility of PredictCBC-1A between thresholds of 4-10% 10-year CBC risk for BRCA1/2 mutation carriers and non-carriers. CONCLUSIONS We developed a reasonably calibrated model to predict the risk of CBC in women of European-descent; however, prediction accuracy was moderate. Our model shows potential for improved risk counseling, but decision-making regarding contralateral preventive mastectomy, especially in the general breast cancer population where limited information of the mutation status in BRCA1/2 is available, remains challenging.
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Affiliation(s)
- Daniele Giardiello
- Division of Molecular Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Michael Hauptmann
- Institute of Biometry and Registry Research, Brandenburg Medical School, Neuruppin, Germany
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Muriel A Adank
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek hospital, Family Cancer Clinic, Amsterdam, The Netherlands
| | - Delal Akdeniz
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Carl Blomqvist
- Department of Oncology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Oncology, Örebro University Hospital, Örebro, Sweden
| | - Stig E Bojesen
- Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Manjeet K Bolla
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Mariël Brinkhuis
- East-Netherlands, Laboratory for Pathology, Hengelo, The Netherlands
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Cancer Epidemiology Group, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Peter Devilee
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Alison M Dunning
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Douglas F Easton
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Diana M Eccles
- Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Peter A Fasching
- Department of Medicine Division of Hematology and Oncology, University of California at Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center ER-EMN, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Jonine Figueroa
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh Medical School, Edinburgh, UK
- Cancer Research UK Edinburgh Centre, Edinburgh, UK
- Department of Health and Human Services, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Henrik Flyger
- Department of Breast Surgery, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Montserrat García-Closas
- Department of Health and Human Services, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Lothar Haeberle
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center ER-EMN, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Christopher A Haiman
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - Ute Hamann
- Molecular Genetics of Breast Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Anna Jakubowska
- Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
- Independent Laboratory of Molecular Biology and Genetic Diagnostics, Pomeranian Medical University, Szczecin, Poland
| | - Audrey Jung
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Renske Keeman
- Division of Molecular Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Iris Kramer
- Division of Molecular Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Diether Lambrechts
- VIB Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory for Translational Genetics, Department of Human Genetics, University of Leuven, Leuven, Belgium
| | - Loic Le Marchand
- University of Hawaii Cancer Center, Epidemiology Program, Honolulu, HI, USA
| | - Annika Lindblom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Lubiński
- Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Mehdi Manoochehri
- Molecular Genetics of Breast Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Luigi Mariani
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Heli Nevanlinna
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Hester S A Oldenburg
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Saskia Pelders
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Paul D P Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Mitul Shah
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Vincent T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Melissa C Southey
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Department of Clinical Pathology, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandra J van den Broek
- Division of Molecular Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Flora E van Leeuwen
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - Chantal van Ongeval
- Leuven Multidisciplinary Breast Center, Department of Oncology, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Laura J Van't Veer
- Division of Molecular Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Qin Wang
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Camilla Wendt
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | | | - Maartje J Hooning
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands.
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11
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Kaiser K, Cameron KA, Beaumont J, Garcia SF, Lacson L, Moran M, Karavites L, Rodgers C, Kulkarni S, Hansen NM, Khan SA. What does risk of future cancer mean to breast cancer patients? Breast Cancer Res Treat 2019; 175:579-584. [PMID: 30840165 PMCID: PMC6535122 DOI: 10.1007/s10549-019-05182-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE Newly diagnosed breast cancer patients greatly overestimate their risk of developing contralateral breast cancer (CBC). Better understanding of patient conceptions of risk would facilitate doctor-patient communication and surgical decision making. In this mixed methods study, we prospectively examined breast cancer patients' perceived risk of future cancer and the reported factors that drove their risk perceptions. METHODS Women age 21-60 diagnosed with breast cancer without a BRCA mutation or known distant metastases completed a study interview between surgical consult and surgical treatment. Participants completed a 12-item Perceived Risk Questionnaire, which assessed 10-year and lifetime risks of ipsilateral local recurrence, CBC, and distant recurrence. Patients provided qualitative explanations for their answers. RESULTS Sixty-three patients completed study interviews (mean age 50.3). Participants were primarily White (85.7%) and 90.5% had attended college. Patients estimated their 10-year risk of CBC as 22.0%, nearly 4 times the established 10-year risk. Women attributed their risk perceptions to "gut feelings" about future cancer, even when women knew those feelings contradicted medically established risk. Perceptions of risk also reflected beliefs that cancer is random and that risk for local recurrence, CBC, and distant recurrence are the same. CONCLUSIONS Our findings point to the need for novel ways of presenting factual information regarding both risk of recurrence and of new primary cancers, as well as the necessity of acknowledging cognitive and affective processes many patients use when conceptualizing risk. By differentiating women's intuitive feelings about risk from their knowledge of medically estimated risk, doctors can enhance informed decision making.
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Affiliation(s)
- Karen Kaiser
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Avenue, Suite 2700, 60611, Chicago, IL, USA.
| | - Kenzie A Cameron
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Avenue, Suite 2700, 60611, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Sofia F Garcia
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Avenue, Suite 2700, 60611, Chicago, IL, USA
| | - Leilani Lacson
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Avenue, Suite 2700, 60611, Chicago, IL, USA
| | | | | | - Chiara Rodgers
- American Association of Hip and Knee Surgeons, Chicago, IL, USA
| | - Swati Kulkarni
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nora M Hansen
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Seema A Khan
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Chowdhury M, Euhus D, O'Donnell M, Onega T, Choudhary PK, Biswas S. Dose-dependent effect of mammographic breast density on the risk of contralateral breast cancer. Breast Cancer Res Treat 2018; 170:143-148. [PMID: 29511964 PMCID: PMC6290471 DOI: 10.1007/s10549-018-4736-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/26/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE Increased mammographic breast density is a significant risk factor for breast cancer. It is not clear if it is also a risk factor for the development of contralateral breast cancer. METHODS The data were obtained from Breast Cancer Surveillance Consortium and included women diagnosed with invasive breast cancer or ductal carcinoma in situ between ages 18 and 88 and years 1995 and 2009. Each case of contralateral breast cancer was matched with three controls based on year of first breast cancer diagnosis, race, and length of follow-up. A total of 847 cases and 2541 controls were included. The risk factors included in the study were mammographic breast density, age of first breast cancer diagnosis, family history of breast cancer, anti-estrogen treatment, hormone replacement therapy, menopausal status, and estrogen receptor status, all from the time of first breast cancer diagnosis. Both univariate analysis and multivariate conditional logistic regression analysis were performed. RESULTS In the final multivariate model, breast density, family history of breast cancer, and anti-estrogen treatment remained significant with p values less than 0.01. Increasing breast density had a dose-dependent effect on the risk of contralateral breast cancer. Relative to 'almost entirely fat' category of breast density, the adjusted odds ratios (and p values) in the multivariate analysis for 'scattered density,' 'heterogeneously dense,' and 'extremely dense' categories were 1.65 (0.036), 2.10 (0.002), and 2.32 (0.001), respectively. CONCLUSION Breast density is an independent and significant risk factor for development of contralateral breast cancer. This risk factor should contribute to clinical decision making.
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Affiliation(s)
- Marzana Chowdhury
- Department of Mathematical Sciences, University of Texas at Dallas, 800 W Campbell Rd FO 35, Richardson, TX, 75080, USA
| | - David Euhus
- Division of Surgical Oncology, Johns Hopkins University, Baltimore, USA
| | | | - Tracy Onega
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Pankaj K Choudhary
- Department of Mathematical Sciences, University of Texas at Dallas, 800 W Campbell Rd FO 35, Richardson, TX, 75080, USA.
| | - Swati Biswas
- Department of Mathematical Sciences, University of Texas at Dallas, 800 W Campbell Rd FO 35, Richardson, TX, 75080, USA.
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13
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Grimm LJ, Shelby RA, Knippa EE, Langman EL, Miller LS, Whiteside BE, Soo MSC. Patient Perceptions of Breast Cancer Risk in Imaging-Detected Low-Risk Scenarios and Thresholds for Desired Intervention: A Multi-Institution Survey. J Am Coll Radiol 2018; 15:911-919. [PMID: 29606632 DOI: 10.1016/j.jacr.2018.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/29/2018] [Accepted: 02/06/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine women's perceptions of breast cancer risk and thresholds for desiring biopsy when considering BI-RADS 3 and 4A scenarios and recommendations, respectively. MATERIALS AND METHODS Women presenting for screening mammography from five geographically diverse medical centers were surveyed. Demographic information and baseline anxiety were queried. Participants were presented with scenarios of short-term imaging follow-up recommendations (ie, BI-RADS 3) and biopsy recommendations (ie, BI-RADS 4A) for low-risk mammographic abnormalities and asked to estimate their breast cancer risk for each scenario. Participants reported the threshold (ie, likelihood of cancer) where they would feel comfortable undergoing short-term imaging follow-up and biopsy and their anticipated regret for choosing short-term follow-up versus biopsy. RESULTS Analysis of 2,747 surveys showed that participants estimated breast cancer risk of 32.8% for a BI-RADS 3 and 41.1% for a BI-RADS 4A scenarios are significantly greater rates than clinically established rates (<2% [P < .001] and 2%-10% [P < .001], respectively). Over one-half (55.4%) of participants reported they would never want imaging follow-up if there was any chance of cancer; two-thirds (66.2%) reported they would desire biopsy if there was any chance of cancer. Participants reported greater anticipated regret (P < .001) and less relief and confidence (P < .001) with the decision to undergo follow-up imaging versus biopsy. CONCLUSION Women overestimate breast cancer risk associated with both BI-RADS 3 and 4A scenarios and desire very low biopsy thresholds. Greater anticipated regret and less relief and confidence was reported with the choice to undergo short-term imaging follow-up compared with biopsy.
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Affiliation(s)
- Lars J Grimm
- Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - Rebecca A Shelby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| | - Emily E Knippa
- Department of Radiology, University of Texas Southwestern, Dallas, Texas
| | - Eun L Langman
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Lauren S Miller
- Riverside Radiology and Interventional Associates, Inc., Columbus, Ohio
| | - Beth E Whiteside
- Department of Radiology, Albany Medical Center, Albany, New York
| | - Mary Scott C Soo
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Riedel F, Hennigs A, Hug S, Schaefgen B, Sohn C, Schuetz F, Golatta M, Heil J. Is Mastectomy Oncologically Safer than Breast-Conserving Treatment in Early Breast Cancer? Breast Care (Basel) 2017; 12:385-390. [PMID: 29456470 PMCID: PMC5803719 DOI: 10.1159/000485737] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIM To describe and discuss the evidence for oncological safety of different procedures in oncological breast surgery, i.e. breast-conserving treatment versus mastectomy. METHODS Literature review and discussion. RESULTS Oncological safety in breast cancer surgery has many dimensions. Breast-conserving treatment has been established as the standard surgical procedure for primary breast cancer and fits to the preferences of most breast cancer patients concerning oncological safety and aesthetic outcome. CONCLUSIONS Breast-conserving treatment is safe. Nonetheless, the preferences of the individual patients in their consideration of breast conservation versus mastectomy should be integrated into routine treatment decisions.
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Affiliation(s)
| | | | | | | | | | | | | | - Jörg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
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15
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Hegde JV, Wang X, Attai DJ, DiNome ML, Kusske A, Hoyt AC, Hurvitz SA, Weidhaas JB, Steinberg ML, McCloskey SA. Assessing the Effect of Lifetime Contralateral Breast Cancer Risk on the Selection of Contralateral Prophylactic Mastectomy for Unilateral Breast Cancer. Clin Breast Cancer 2017; 18:e205-e218. [PMID: 29050918 DOI: 10.1016/j.clbc.2017.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/11/2017] [Accepted: 09/14/2017] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Contralateral prophylactic mastectomy (CPM) rates are rising, with fear implicated as a contributing factor. This study used a contralateral breast cancer (CBC) risk stratification tool to assess whether the selection of CPM is reflective of future CBC risk. PATIENTS AND METHODS This retrospective study evaluated 404 women with unilateral breast cancer treated with breast conservation, unilateral mastectomy, or bilateral mastectomy within a single multidisciplinary clinic. Women were evaluated by the Manchester risk tool to calculate lifetime CBC risk. Logistic regression analysis was used to evaluate whether CBC risk was associated with CPM, and the clinical rationale for prophylactic mastectomy justification was recorded. RESULTS Sixty-two percent underwent breast conservation, 18% unilateral mastectomy, and 20% bilateral mastectomy. In the CPM cohort, 36% had > 20% calculated lifetime CBC risk. In the invasive cohort, younger age (odds ratio 2.65, P < .0001) and genetic mutation positivity (odds ratio 35.39, P = .019) independently predicted CPM. Other contributing factors included benign contralateral breast findings (29%) and recommendations against breast conservation due to disease burden (28%). Six percent selected CPM as a result of an unsubstantiated fear regarding breast cancer. CONCLUSION The majority of women (63%) who selected CPM had < 20% CBC risk. In these lower-risk women selecting CPM, factors increasing reasonable fear dominated surgical choice (81% of this subset).
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Affiliation(s)
- John V Hegde
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA.
| | - Xiaoyan Wang
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Deanna J Attai
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Maggie L DiNome
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Amy Kusske
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Anne C Hoyt
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA
| | - Sara A Hurvitz
- Division of Hematology/Oncology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Joanne B Weidhaas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - Susan A McCloskey
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
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16
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Kim HS, Kang SH. Utility of Regular Radiological Follow-up on Early Detection of Contralateral Malignancy and Long-term Outcomes in Metachronous Bilateral Breast Cancer Patients. KOSIN MEDICAL JOURNAL 2017. [DOI: 10.7180/kmj.2017.32.1.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives We investigated the utility of regular radiological follow-up on the early detection of contralateral breast cancer(CBC) and prognosis in patients with metachronous bilateral breast cancer. Methods Between 1983 and 2010, 49(2.1%) metachronous bilateral breast cancer patients were identified among a total of 2,343 cases of invasive or in situ breast carcinomas. We reviewed the patients' medical records including age, stage, duration between the first and second breast cancer diagnosis, operation method, recurrence, and breast cancer-specific survival. Results The mean ages at the first and second breast cancer diagnosis were 43.8 and 49.2 years, respectively. The mean duration between the first and second breast cancer diagnosis was 68.9 months (range, 7–266 months). Regular radiological follow-up with annual mammography(MMG) with or without ultrasonography was conducted in 28 patients (63.6%, Group 1), and no regular follow-up was performed in 12 patients (27.3%, Group 2). The median follow-up duration was 150 months. In a comparative analysis, Group 1 patients exhibited more stage 0 and stage 1 malignancies (82.1% vs. 25%, P =0.006) as second cancer and the same or an improved stage (71.4% vs. 33.3%, P =0.042) of second cancer compared to Group 2 patients. Breast cancer-specific survival rates between the two groups after the first cancer occurrence were higher in Group 1 patients compared to Group 2 patients, although this did not reach statistical significance. Conclusion Screening for CBC with regular radiological follow-up could result in early detection of CBC, less invasive surgical procedures, and enhanced breast cancer-specific survival outcomes.
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Collins K, Gee M, Clack A, Wyld L. The psychosocial impact of contralateral risk reducing mastectomy (CRRM) on women: A rapid review. Psychooncology 2017; 27:43-52. [PMID: 28453892 DOI: 10.1002/pon.4448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES For women who have been diagnosed with unilateral breast cancer, there is an increasing trend for them to request removal of the contralateral healthy breast, the so-called contralateral risk reducing mastectomy (CRRM). The current literature is only just beginning to identify patient-reported reasons for undergoing CRRM and associated patient-reported outcomes. It is also unclear whether women at moderate/high risk of developing a subsequent primary contralateral breast cancer report similar outcomes to those considered to be at low/average risk. This lack of knowledge provides the rationale for this review. METHODS A rapid review methodology was undertaken to identify and explore the published research literature focused on the longer term (>5 y) psychosocial impacts on women who undergo CRRM. RESULTS Fifteen studies were identified. No UK studies were identified. High satisfaction and psychosocial well-being were consistently reported across all studies. Reducing the risk of a subsequent contralateral breast cancer and therefore reducing cancer-related anxiety, and satisfaction with cosmesis, were key themes running across all studies explaining satisfaction. Dissatisfaction was associated with adverse effects such as poor cosmesis, body image changes, femininity, sexual relationships, reoperations for acute and longer term complications, and reconstructive problems. CONCLUSIONS Satisfaction and psychological well-being following CRRM was consistently high across all studies. However, the findings suggest women need to be more fully informed of the risks and benefits of CRRM and/or immediate/delayed reconstruction to support informed decision making.
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Affiliation(s)
- Karen Collins
- Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Melanie Gee
- Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Anna Clack
- Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Lynda Wyld
- Academic Unit of Surgical Oncology, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
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Baptiste DF, MacGeorge EL, Venetis MK, Mouton A, Friley LB, Pastor R, Hatten K, Lagoo J, Clare SE, Bowling MW. Motivations for contralateral prophylactic mastectomy as a function of socioeconomic status. BMC WOMENS HEALTH 2017; 17:10. [PMID: 28143474 PMCID: PMC5286852 DOI: 10.1186/s12905-017-0366-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 01/27/2017] [Indexed: 01/04/2023]
Abstract
Background Despite no demonstrated survival advantage for women at average risk of breast cancer, rates of contralateral prophylactic mastectomy (CPM) continue to increase. Research reveals women with higher socioeconomic status (SES) are more likely to select CPM. This study examines how indicators of SES, age, and disease severity affect CPM motivations. Methods Patients (N = 113) who underwent CPM at four Indiana University affiliated hospitals completed telephone interviews in 2013. Participants answered questions about 11 CPM motivations and provided demographic information. Responses to motivation items were factor analyzed, resulting in 4 motivational factors: reducing long-term risk, symmetry, avoiding future medical visits, and avoiding treatments. Results Across demographic differences, reducing long-term risk was the strongest CPM motivation. Lower income predicted stronger motivation to reduce long-term risk and avoid treatment. Older participants were more motivated to avoid treatment; younger and more-educated patients were more concerned about symmetry. Greater severity of diagnosis predicted avoiding treatments. Conclusions Reducing long-term risk is the primary motivation across groups, but there are also notable differences as a function of age, education, income, and disease severity. To stop the trend of increasing CPM, physicians must tailor patient counseling to address motivations that are consistent across patient populations and those that vary between populations. Electronic supplementary material The online version of this article (doi:10.1186/s12905-017-0366-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dadrie F Baptiste
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 202, Indianapolis, IN, 46202, USA.,Present address: William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Erina L MacGeorge
- Department of Communication Arts and Sciences, Pennsylvania State University, 234 Sparks Building, University Park, PA, 16802, USA
| | - Maria K Venetis
- Brian Lamb School of Communication, Purdue University, BRNG 2264, 100 North University Street, West Lafayette, IN, 47907-2098, USA
| | - Ashton Mouton
- Brian Lamb School of Communication, Purdue University, BRNG 2264, 100 North University Street, West Lafayette, IN, 47907-2098, USA
| | - L Brooke Friley
- Brian Lamb School of Communication, Purdue University, BRNG 2264, 100 North University Street, West Lafayette, IN, 47907-2098, USA.,Present address: Department of Communication and Media, Texas A&M-Corpus Christi, 6300 Ocean Dr., Corpus Christi, TX, 78412, USA
| | - Rebekah Pastor
- Brian Lamb School of Communication, Purdue University, BRNG 2264, 100 North University Street, West Lafayette, IN, 47907-2098, USA.,Present address: CoreClarity, PO Box 863692, Plano, TX, 75086, USA
| | - Kristen Hatten
- Brian Lamb School of Communication, Purdue University, BRNG 2264, 100 North University Street, West Lafayette, IN, 47907-2098, USA.,Present address: School of Communication, Western Michigan University, 1903 W Michigan Ave., Kalamazoo, MI, 49008, USA
| | - Janaka Lagoo
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 202, Indianapolis, IN, 46202, USA.,Present address: Ariadne Labs, 401 Park Drive, Boston, MA, 02215, USA
| | - Susan E Clare
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 4-113, Chicago, IL, 60611, USA.
| | - Monet W Bowling
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 202, Indianapolis, IN, 46202, USA. .,Present address: Hendricks Regional Health, 1000 East Main Street, Danville, IN, 46122, USA.
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Yao K, Belkora J, Sisco M, Rosenberg S, Bedrosian I, Liederbach E, Wang C. Survey of the Deficits in Surgeons' Knowledge of Contralateral Prophylactic Mastectomy. JAMA Surg 2016; 151:391-3. [PMID: 26606424 DOI: 10.1001/jamasurg.2015.3601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston Hospital, Evanston, Illinois
| | - Jeff Belkora
- University of California, San Francisco, School of Medicine, San Francisco
| | - Mark Sisco
- Department of Surgery, NorthShore University HealthSystem, Evanston Hospital, Evanston, Illinois
| | | | | | - Erik Liederbach
- Department of Surgery, NorthShore University HealthSystem, Evanston Hospital, Evanston, Illinois
| | - Chihsiung Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, Illinois
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Davies KR, Brewster AM, Bedrosian I, Parker PA, Crosby MA, Peterson SK, Shen Y, Volk RJ, Cantor SB. Outcomes of contralateral prophylactic mastectomy in relation to familial history: a decision analysis (BRCR-D-16-00033). Breast Cancer Res 2016; 18:93. [PMID: 27650678 PMCID: PMC5028980 DOI: 10.1186/s13058-016-0752-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 08/11/2016] [Indexed: 12/20/2022] Open
Abstract
Background Family history of breast cancer is associated with an increased risk of contralateral breast cancer (CBC) even in the absence of mutations in the breast cancer susceptibility genes BRCA1/2. We compared quality-adjusted survival after contralateral prophylactic mastectomy (CPM) with surveillance only (no CPM) among women with breast cancer incorporating the degree of family history. Methods We created a microsimulation model for women with first-degree, second-degree, and no family history treated for a stage I, II, or III estrogen receptor (ER)-positive or ER-negative breast cancer at the ages of 40, 50, 60, and 70. The model incorporated a 10-year posttreatment period for risk of developing CBC and/or dying of the primary cancer or CBC. For each patient profile, we used 100,000 microsimulation trials to estimate quality-adjusted life expectancy for the clinical strategies CPM and no CPM. Results CPM showed minimal improvement on quality-adjusted life expectancy among women age 50–60 with no or a unilateral first-degree or second-degree family history (decreasing from 0.31 to –0.06 quality-adjusted life-years (QALYs)) and was unfavorable for most subgroups of women age 70 with stage III breast cancer regardless of degree of family history (range –0.08 to –0.02 QALYs). Sensitivity analysis showed that the highest predicted benefit of CPM assuming 95 % risk reduction in CBC was 0.57 QALYs for a 40-year-old woman with stage I breast cancer who had a first-degree relative with bilateral breast cancer. Conclusions Women age 40 with stage I breast cancer and a first-degree relative with bilateral breast cancer have a QALY benefit from CPM similar to that reported for BRCA1/2 mutation carriers. For most subgroups of women, CPM has a minimal to no effect on quality-adjusted life expectancy, irrespective of family history of breast cancer.
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Affiliation(s)
- Kalatu R Davies
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Unit 1444, P.O. Box 301402, Houston, TX, 77230-1402, USA
| | - Abenaa M Brewster
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patricia A Parker
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Melissa A Crosby
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Unit 1444, P.O. Box 301402, Houston, TX, 77230-1402, USA
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Unit 1444, P.O. Box 301402, Houston, TX, 77230-1402, USA.
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Landercasper J, Bailey L, Berry TS, Buras RR, Degnim AC, Fayanju OM, Froman J, Gass J, Greenberg C, Mautner SK, Krontiras H, Rao R, Sowden M, Tjoe JA, Wexelman B, Wilke L, Chen SL. Measures of Appropriateness and Value for Breast Surgeons and Their Patients: The American Society of Breast Surgeons Choosing Wisely (®) Initiative. Ann Surg Oncol 2016; 23:3112-8. [PMID: 27334216 PMCID: PMC4999471 DOI: 10.1245/s10434-016-5327-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Current breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely (®) Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged. METHODS The Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely (®) Campaign. The resulting list of "appropriateness" measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below. RESULTS (1) Don't routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don't routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don't routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don't routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don't routinely perform a double mastectomy in patients who have a single breast with cancer. CONCLUSIONS The ASBrS list for the Choosing Wisely (®) campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.
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Affiliation(s)
| | - Lisa Bailey
- Bay Area Breast Surgeons, Inc., Oakland, CA, USA
| | | | | | | | | | | | | | - Caprice Greenberg
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
| | | | | | - Roshni Rao
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Lee Wilke
- University of Wisconsin of Madison, Madison, WI, USA
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Goyal U, Locke A, Smith-Raymond L, Georgiev GN. Simple shielding reduces dose to the contralateral breast during prone breast cancer radiotherapy. Med Dosim 2016; 41:159-65. [DOI: 10.1016/j.meddos.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/15/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
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