Contralateral prophylactic mastectomy and implications for breast reconstruction

Trends in Contralateral Prophylactic Mastectomies Before and After the American Society of Breast Surgeons Consensus Statement

INTRODUCTION

In 2016, an American Society of Breast Surgeons (ASBrS) statement discouraged contralateral prophylactic mastectomy (CPM) in average-risk women with unilateral breast cancer. Despite evidence of no oncologic benefit and related attempts to discourage the practice, CPM remains prevalent. This study aims to assess CPM trends post-ASBrS statement and factors associated with these trends.

METHODS

A retrospective cohort study of patients with primary unilateral breast cancer undergoing complete mastectomy at a single-tertiary center between January 2014 and December 2020 was performed. We assessed the proportion opting for CPM, compared pre- and post-ASBrS statement CPM rates, and examined associated patient and tumor factors. Pearson's Chi-square test, Fisher's exact test, and equal variance t-tests were used to compare subsets who underwent CPM versus those who did not.

RESULTS

Of 605 patients, 161 (27%) underwent CPM during our study period, with the median follow-up time for all patients being 58 mo (IQR: 38 to 81). Among all patients, CPM rates ranged from 30% to 14% before the ASBrS statement and then declined from 36% to 19% after the statement. For average-risk patients (no genetic mutation), these rates ranged from 20.2% to 10.2% from 2014 to 2016 and had a steady decline from 23.2% in 2017 to 13.2% in 2020. Only two cases (1.2%) had incidental contralateral breast cancer. Patients undergoing CPM tended to be younger, more likely to have a breast cancer gene mutation, pursue reconstruction, and elect for nipple- or skin-sparing mastectomy. Recurrence and mortality events did not differ significantly. Genetic testing and pathogenic variant rates were greater among CPM patients.

CONCLUSIONS

After an initial time lag, CPM rates appear to be decreasing post-ASBrS statement, with ongoing data needed to confirm this trend. CPM rates among breast cancer gene patients align appropriately with guidelines catering to this higher risk population. Better educational tools and decision aids may impact CPM trends and facilitate shared decision-making.

Are There Disparities in Breast Reconstruction After Contralateral Prophylactic Mastectomy?

INTRODUCTION

Despite national guidelines against contralateral prophylactic mastectomy (CPM) in low- to moderate-risk breast cancer, CPM use continues to rise. Breast reconstruction improves health-related quality of life and satisfaction among women undergoing mastectomy. Given the lack of data regarding factors associated with reconstruction after CPM and the known benefits of reconstruction, we sought to investigate whether disparities exist in receipt of reconstruction after CPM.

METHODS

The 2004-2017 National Cancer Database was queried to identify women diagnosed with breast cancer who underwent unilateral mastectomy with CPM. Patients were divided into two groups: those who underwent planned reconstruction at any timepoint and those who did not. A secondary analysis comparing types of reconstruction (tissue, implant, combined) was conducted. Patient, tumor, and demographic characteristics were analyzed using chi-square test and odds ratios were calculated using generalized estimating equations.

RESULTS

The cohort included 1,73,249 women: 95,818 (55.3%) underwent reconstruction and 77,431 (45.7%) did not. Both the rate CPM and the proportion of women undergoing reconstruction after CPM increased between 2004 and 2017. Of the women who had reconstruction, 40,840 (51.7%) received implants, 29,807 (37.7%) had tissue, and 8352 (10.6%) had combined reconstruction. After adjusted analysis, factors associated with reconstruction were young age, Hispanic ethnicity, private insurance, and living in an area with the highest education and median income (P < 0.01). Patients who underwent reconstruction were less likely to have radiation (P < 0.01) and chemotherapy (P < 0.01), more likely to have stage I disease (P < 0.01), and to be treated at an integrated cancer center (P < 0.01).

CONCLUSIONS

Reconstruction after CPM is disproportionately received by younger women, Hispanics, those with private insurance, and higher socioeconomic status and education. While the rate of reconstruction after CPM is increasing, there remain significant disparities. Conscious efforts must be made to eliminate these disparities, especially given the known benefits of reconstruction after mastectomy.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy

BACKGROUND

Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy.

METHODS

A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected.

RESULTS

In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients.

CONCLUSIONS

There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Patient-reported Quality of Life After Breast-conserving Surgery With Radiotherapy Versus Mastectomy and Reconstruction

OBJECTIVE

To compare long-term quality of life (QOL) outcomes in breast cancer survivors who received breast-conserving surgery with radiotherapy (BCS+RT) with those who received a mastectomy and reconstructive surgery (Mast+Recon) without radiotherapy and identify other important factors.

BACKGROUND

The long-term differences in patient-reported QOL outcomes following BCS+RT and Mast+Recon are not well understood.

METHODS

We identified patients from the Texas Cancer Registry with stage 0-II breast cancer diagnosed in 2009-2014 after BCS+RT or Mast+Recon without radiotherapy. Sampling was stratified by age and race and ethnicity. A paper survey was sent to 4800 patients which included validated BREAST-Q and PROMIS modules. Multivariable linear regression models were implemented for each outcome. Minimal clinically important difference for BREAST-Q and PROMIS modules, respectively, was 4 points and 2 points.

RESULTS

Of 1215 respondents (25.3% response rate), 631 received BCS+RT and 584 received Mast+Recon. The median interval from diagnosis to survey completion was 9 years. In adjusted analysis, Mast+Recon was associated with worse BREAST-Q psychosocial well-being (effect size: -3.80, P =0.04) and sexual well-being (effect size: -5.41, P =0.02), but better PROMIS physical function (effect size: 0.54, P =0.03) and similar BREAST-Q satisfaction with breasts, physical well-being, and PROMIS upper extremity function ( P >0.05) compared with BCS+RT. Only the difference in sexual well-being reached clinical significance. Older (≥65) patients receiving BCS+RT and younger (<50) patients receiving autologous Mast+Recon typically reported higher QOL scores. Receipt of chemotherapy was associated with detriments to multiple QOL domains.

CONCLUSIONS

Patients who underwent Mast+Recon reported worse long-term sexual well-being compared with BCS+RT. Older patients derived a greater benefit from BCS+RT, while younger patients derived a greater benefit from Mast+Recon. These data inform preference-sensitive decision-making for women with early-stage breast cancer.

EBCC-13 manifesto: Balancing pros and cons for contralateral prophylactic mastectomy

After a diagnosis of unilateral breast cancer, increasing numbers of patients are requesting contralateral prophylactic mastectomy (CPM), the surgical removal of the healthy breast after diagnosis of unilateral breast cancer. It is important for the community of breast cancer specialists to provide meaningful guidance to women considering CPM. This manifesto discusses the issues and challenges of CPM and provides recommendations to improve oncological, surgical, physical and psychological outcomes for women presenting with unilateral breast cancer: (1) Communicate best available risks in manageable timeframes to prioritise actions; better risk stratification and implementation of risk-assessment tools combining family history, genetic and genomic information, and treatment and prognosis of the first breast cancer are required; (2) Reserve CPM for specific situations; in women not at high risk of contralateral breast cancer (CBC), ipsilateral breast-conserving surgery is the recommended option; (3) Encourage patients at low or intermediate risk of CBC to delay decisions on CPM until treatment for the primary cancer is complete, to focus on treating the existing disease first; (4) Provide patients with personalised information about the risk:benefit balance of CPM in manageable timeframes; (5) Ensure patients have an informed understanding of the competing risks for CBC and that there is a realistic plan for the patient; (6) Ensure patients understand the short- and long-term physical effects of CPM; (7) In patients considering CPM, offer psychological and surgical counselling before surgery; anxiety alone is not an indication for CPM; (8) Eliminate inequality between countries in reimbursement strategies; CPM should be reimbursed if it is considered a reasonable option resulting from multidisciplinary tumour board assessment; (9) Treat breast cancer patients at specialist breast units providing the entire patient-centred pathway.

Prophylactic mastectomy and occult malignancy: Surgical and imaging considerations

BACKGROUND

Sentinel node biopsy (SLNB) is not routinely recommended for patients undergoing prophylactic mastectomy (PM), yet omission remains a subject of debate among surgeons. A modern patient cohort was examined to determine occult malignancy (OM) incidence within PM specimens to reinforce current recommendations.

METHODS

All PM performed over a 5-year period were retrospectively identified, including women with unilateral breast cancer who underwent synchronous or delayed contralateral PM or women with elevated cancer risk who underwent bilateral PM.

RESULTS

The study population included 772 patients (598 CPM, 174 BPM) with a total of 39 OM identified: 17 invasive cancers (14 CPM, 3 BPM) and 22 DCIS (19 CPM, 3 BPM). Of the 86 patients for whom SLNB was selectively performed, 1 micrometastasis was identified. In the CPM cohort, risk of OM increased with age, presence of LCIS of either breast, or presence of a non-BRCA high-penetrance gene mutation, while preoperative magnetic resonance imaging was associated with lower likelihood of OM.

CONCLUSIONS

Given the low incidence of invasive OM in this updated series, routine SLNB is of low value for patients undergoing PM. For patients with indeterminate radiographic findings, discordant preoperative biopsies, LCIS, or non-BRCA high-penetrance gene mutations, selective SLNB implementation could be considered.

Complications Associated with Contralateral Prophylactic Mastectomy: A Systematic Review and Meta-Analysis

BACKGROUND

No prior systematic review and meta-analysis has aimed to answer the frequently-studied question: does a contralateral prophylactic mastectomy (CPM) increase complication risk for unilateral breast cancer patients undergoing unilateral mastectomy (UM)?

METHODS

A February 2021 search for studies on complications of UM+CPM identified 15 articles meeting inclusion criteria. Meta-analyses were conducted to compare complications of 1) diseased versus CPM breasts for UM+CPM patients and 2) patients undergoing UM+CPM versus UM alone when grouped by their different reconstructive methods. Outcomes included incidence of any complication and any severe complication requiring re-operation, re-admission, or delay in adjuvant therapy.

RESULTS

For all UM+CPM patients, the diseased breast was slightly more prone to complications versus the CPM breast (RR:1.24, CI:1.02-1.51). In studies that stratified by reconstructive method, incidence of complications was higher for UM+CPM versus UM alone for patients with no reconstruction (RR:2.03, CI:1.38-2.98), prosthetic-based reconstruction (RR:1.42, CI:1.13-1.80), and autologous reconstruction (RR:1.32, CI:1.09-1.61). Similar results were found by the only prospective trial on the topic, which showed the same for more severe complications. Other smaller retrospective studies that did not stratify by reconstructive method showed similar complications for UM+CPM versus UM alone (RR:1.06, CI:0.79-1.42). These groups had similar incidences of complication-related delay in adjuvant therapy, as demonstrated by one study.

CONCLUSIONS

After UM+CPM, CPM breasts incur only slightly fewer complications. Stronger evidence supports more complications for UM+CPM than UM alone, although some studies report no difference. More work is needed to determine the effect of complications on timing of adjuvant therapy.

Development of the Breast Surgical Oncology Fellowship in the United States

The surgical treatment of breast cancer has rapidly evolved over the past 50 years, progressing from Halsted's radical mastectomy to a public campaign of surgical options, aesthetic reconstruction, and patient empowerment. Sparked by the research of Dr. Bernard Fisher and the first National Surgical Adjuvant Breast and Bowel Project trial in 1971, the field of breast surgery underwent significant growth over the next several decades, enabling general surgeons to limit their practices to the breast. High surgical volumes eventually led to the development of the first formal breast surgical oncology fellowship in a large community-based hospital at Baylor University Medical Center in 1982. The establishment of the American Society of Breast Surgeons, as well as several landmark clinical trials and public campaign efforts, further contributed to the advancement of breast surgery. In 2003, the Society of Surgical Oncology (SSO), in partnership with the American Society of Breast Surgeons and the American Society of Breast Disease, approved its first fellowship training program in breast surgical oncology. Since that time, the number of American fellowship programs has increased to approximately 60 programs, focusing not only on training in breast surgery, but also in medical oncology, radiation oncology, pathology, breast imaging, and plastic and reconstructive surgery. This article focuses on the happenings in the United States that led to the transition of breast surgery from a subset of general surgery to its own specialized field.

Direct comparison of CGCRYODERM and DermACELL in the same patient for outcomes in bilateral implant-based breast reconstruction: a retrospective case series

Background

The use of acellular dermal matrix (ADM) has been popularized in implant-based breast reconstruction (IBR). However, it is still controversial if ADM-associated complication rates differ with varying types of ADM products. The aim of this study was to compare postoperative complications between CGCRYODERM and DermACELL.

Methods

A retrospective chart review was performed on 32 patients (64 breasts) who underwent bilateral prosthetic breast reconstruction between June 2015 and December 2019. All patients received two different ADMs in each breast during the surgery. Demographic variables, operative characteristics, and postoperative outcomes were compared between the cryopreserved and pre-hydrated ADM.

Results

The overall major and minor postoperative complications developed in 7 and 1 out of 32 patients, respectively. Seroma and infection were the most common complications. There were no cases that infection and/or seroma involved both breasts in one individual. No significant differences were observed in terms of seroma, infection, hematoma, mastectomy flap necrosis, or drainage period between the CGCRYODERM and DermACELL groups (P=0.5637, 0.1797, 1.0000, 0.3173, and 0.2925, respectively). There was no case of reconstruction failure leading to explantation.

Conclusions

There were no statistically significant differences in postoperative complications between the two breasts reconstructed with CGCRYODERM and DermACELL in the same patient who underwent bilateral IBR. This is the first study to compare cryopreserved and pre-hydrated ADMs. We suggest that CGCRYODERM is a suitable option with a comparable safety profile for IBR.