Contralateral prophylactic mastectomy and its impact on quality of life

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trends in utilization of contralateral prophylactic mastectomy among different age, racial and ethnic groups

Background

The use of contralateral prophylactic mastectomy (CPM) has increased over the last two decades with variations in the frequency of reconstruction. The objective of this cohort study is to elucidate the use of CPM and reconstruction among underrepresented racial and ethnic groups and women over 65 years.

Methods

Women over 18 years, diagnosed with stages I to III breast cancer who underwent mastectomy from 2004-2017 were identified in the National Cancer Database (NCDB) and grouped into CPM vs. non-CPM. Multivariable analyses were used to examine the associations between CPM and reconstruction with sociodemographic and clinical factors.

Results

A total of 571,649 patients were identified. Patients who underwent CPM were under 50 years (45.9%), White (88.4%) and with private insurance (73.5%). On multivariable analysis, women over 65 years [odds ratio (OR): 0.18, P<0.001], non-White (Black, OR: 0.56, P<0.001) and without private insurance (uninsured, OR: 0.50, P<0.001) had decreased odds of CPM. Women over 65 years (OR: 0.11, P<0.001), non-White (Asian/Pacific Islander, OR: 0.58, P<0.001) and without private insurance (Medicaid, OR: 0.41, P<0.001) had decreased odds of reconstruction.

Conclusions

Non-White women and women over the age of 65 years were less likely to have CPM or reconstruction than their White counterparts from 2004 to 2017. Research is needed to understand factors impacting decision-making.

Predictors of surgery choices in women with early-stage breast cancer in China: a retrospective study

BACKGROUND

The breast-conserving surgery and reconstruction rate in China is relatively low when compared with those in Western countries. Moreover, predictors of surgical choices for women with breast cancer in China have not yet been explored. This study aims to explore differences in the surgical choices of women with different demographic and clinical characteristics and the predictors that influence surgical choices of women with early-stage breast cancer.

METHODS

This retrospective study included women with early-stage (0-II) breast cancer who underwent surgeries at one of two Xiamen University-affiliated hospitals between 2009 and 2017. Using medical records, eleven variables were collected: the woman's age, year of diagnosis, hospital, marital status, payment method, cancer stage, presence of positive axillary lymph node, histology, neoadjuvant chemotherapy, radiotherapy, and the type(s) of surgery they chose. Binary logistic regression was used to analyse predictors of surgical choice.

RESULTS

A total of 1,787 cases were included in this study. Of the total number of women with breast cancer, 61.3% underwent mastectomy without breast reconstruction, 26.4% underwent mastectomy with breast reconstruction, and the remaining 12.2% chose breast-conserving surgery. Women with different demographic and clinical characteristics underwent different types of surgery. Cancer stage, neoadjuvant chemotherapy, radiotherapy, and the choice of hospital were found to be predictors of breast-conserving surgery. Meanwhile, age, year of diagnosis, payment method, neoadjuvant chemotherapy, and the choice of hospital were found to be predictors of reconstruction after mastectomy in women with early-stage breast cancer.

CONCLUSIONS

In China, surgical choices for women with breast cancer have diversified. Healthcare workers should understand the surgical preferences of women of different ages. For early detection of breast cancer, knowledge of breast self-examination and breast cancer screening should be provided. Adequate information about the safety of reconstruction and advocacy for medical insurance coverage of reconstruction should be offer. Breast surgeons need specialised training and standardising protocols towards different types of breast surgery. These actions will help women make better, well-informed decisions about their breast surgeries.

Long-Term Effects of Breast Cancer Surgery, Treatment, and Survivor Care

Women are increasingly surviving breast cancer, but up to 90% experience unexpected long-term sequelae as a result of treatment. Symptoms may include physical, functional, emotional, and psychosocial changes that can dramatically alter the quality of life for breast cancer survivors. Primary care clinicians, including midwives, are likely to care for these women and should be familiar with common symptoms, treatment, and best practices to avoid permanent dysfunction. A holistic approach to assessment, treatment, and referral as needed is the most effective strategy. Although women experience significant changes after breast cancer treatment, many fail to receive thorough assessment of their symptoms, education about interventions, and treatment options to optimize health promoting strategies. Disparities exist in treatment availability, options, and survivorship. Long-term physical changes include anatomic changes, chronic pain, phantom breast pain, axillary web syndrome, and lymphedema. In addition, women may have decreased strength, aerobic capacity, mobility, fatigue, and cognitive dysfunction. Emotional and psychosocial changes include depression, anxiety, fatigue, concerns about body image, and issues with sexuality. Treatment should be multifactorial based on thorough assessment of symptoms and can include medication, exercise, counseling, physical and occupational therapy, and alternative and complementary therapies. Primary care and gynecologic clinicians are well positioned to provide thorough evaluation, education, treatment, and referral for the most common sequelae of mastectomy and breast cancer treatments.

Plastic and Reconstructive Surgeons' Knowledge and Comfort of Contralateral Prophylactic Mastectomy: A Survey of the American Society of Plastic Surgeons

Background: Despite limited oncologic benefit, contralateral prophylactic mastectomy (CPM) rates have increased in the United States over the past 15 years. CPM is often accompanied by breast reconstruction, thereby requiring an interdisciplinary approach between breast and plastic surgeons. Despite this, little is known about plastic surgeons' (PS) perspectives of CPM. The purpose of this study was to assess PS practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process. Methods: An electronic survey was sent to 2,642 members of the American Society of Plastic Surgeons (ASPS). Questions assessed demographics, practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process. Results: ASPS response rate was 12.5% (n = 329). Most responders worked in private practice (69%), were male (81%) and had been in practice for ≥15 years (60%). The median number of CPM reconstructions performed per month was 2-4. Fifty-five percent of PS reported routine attendance at a breast multidisciplinary conference. Responders reported CPM discussion was most likely to be initiated by the patient (51%) followed by the breast surgeon (38%), and plastic surgeon (7.3%). According to PS, the most common reason patients choose CPM is a perceived increased contralateral cancer risk (86%). Most plastic surgeons (63%) assessed the benefits of CPM as worth the risk of additional surgery and the majority (53%) estimated the complication rate at 2X the risk of unilateral surgery. The majority (61%) of PS estimated risk of contralateral cancer in an average risk patient between <2 and 5% over 10 years, which is consistent with data reported from the current literature. Most plastic surgeons (87%) reported that there was no evidence or limited evidence for breast cancer specific survival benefit with CPM. A minority of PS (18.5%) reported discomfort with a patient's choice for CPM. Of those surgeons reporting discomfort, the most common reasons for their reservations were a concern with the risk/benefit ratio of CPM and with lack of patient understanding of expected outcomes. Common reasons for PS comfort with CPM were a respect for autonomy and non-oncologic benefits of CPM. Discussion: To our knowledge, this is the first survey reporting PS perspectives on CPM. According to PS, CPM dialogue appears to be patient driven and dominated by a perceived increased risk of contralateral cancer. Few PS reported discomfort with CPM. While many PS acknowledge both the limited oncologic benefit of CPM and the increased risk of complications, the majority have the opinion that the benefits of CPM are worth the additional risk. This apparent contradiction may be due to an appreciation of the non-oncologic benefits CPM and a desire to respect patients' choices for treatment.

The psychosocial impact of contralateral risk reducing mastectomy (CRRM) on women: A rapid review

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.