Contralateral prophylactic mastectomy: current perspectives

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.

Personalized surgical recommendations and quantitative therapeutic insights for patients with metastatic breast cancer: Insights from deep learning

Background

The role of surgery in metastatic breast cancer (MBC) is currently controversial. Several novel statistical and deep learning (DL) methods promise to infer the suitability of surgery at the individual level.

Objective

The objective of this study was to identify the most applicable DL model for determining patients with MBC who could benefit from surgery and the type of surgery required.

Methods

We introduced the deep survival regression with mixture effects (DSME), a semi-parametric DL model integrating three causal inference methods. Six models were trained to make individualized treatment recommendations. Patients who received treatments in line with the DL models' recommendations were compared with those who underwent treatments divergent from the recommendations. Inverse probability weighting (IPW) was used to minimize bias. The effects of various features on surgery selection were visualized and quantified using multivariate linear regression and causal inference.

Results

In total, 5269 female patients with MBC were included. DSME was an independent protective factor, outperforming other models in recommending surgery (IPW-adjusted hazard ratio [HR] = 0.39, 95% confidence interval [CI]: 0.19-0.78) and type of surgery (IPW-adjusted HR = 0.66, 95% CI: 0.48-0.93). DSME was superior to other models and traditional guidelines, suggesting a higher proportion of patients benefiting from surgery, especially breast-conserving surgery. The debiased effect of patient characteristics, including age, tumor size, metastatic sites, lymph node status, and breast cancer subtypes, on surgery decision was also quantified.

Conclusions

Our findings suggested that DSME could effectively identify patients with MBC likely to benefit from surgery and the specific type of surgery needed. This method can facilitate the development of efficient, reliable treatment recommendation systems and provide quantifiable evidence for decision-making.

Fertility Preservation in BRCA1/2 Germline Mutation Carriers: An Overview

BRCA1 and BRCA2 mutations are responsible for a higher incidence of breast and ovarian cancer (from 55% up to 70% vs. 12% in the general population). If their functions have been widely investigated in the onset of these malignancies, still little is known about their role in fertility impairment. Cancer patients treated with antineoplastic drugs can be susceptible to their gonadotoxicity and, in women, some of them can induce apoptotic program in premature ovarian follicles, progressive depletion of ovarian reserve and, consequently, cancer treatment-related infertility (CTRI). BRCA variants seem to be associated with early infertility, thus accelerating treatment impairment of ovaries and making women face the concrete possibility of an early pregnancy. In this regard, fertility preservation (FP) procedures should be discussed in oncofertility counseling-from the first line of prevention with risk-reducing salpingo-oophorectomy (RRSO) to the new experimental ovarian stem cells (OSCs) model as a new way to obtain in vitro-differentiated oocytes, several techniques may represent a valid option to BRCA-mutated patients. In this review, we revisit knowledge about BRCA involvement in lower fertility, pregnancy feasibility, and the fertility preservation (FP) options available.

Deep learning-guided adjuvant chemotherapy selection for elderly patients with breast cancer

PURPOSE

The efficacy of adjuvant chemotherapy in elderly breast cancer patients is currently controversial. This study aims to provide personalized adjuvant chemotherapy recommendations using deep learning (DL).

METHODS

Six models with various causal inference approaches were trained to make individualized chemotherapy recommendations. Patients who received actual treatment recommended by DL models were compared with those who did not. Inverse probability treatment weighting (IPTW) was used to reduce bias. Linear regression, IPTW-adjusted risk difference (RD), and SurvSHAP(t) were used to interpret the best model.

RESULTS

A total of 5352 elderly breast cancer patients were included. The median (interquartile range) follow-up time was 52 (30-80) months. Among all models, the balanced individual treatment effect for survival data (BITES) performed best. Treatment according to following BITES recommendations was associated with survival benefit, with a multivariate hazard ratio (HR) of 0.78 (95% confidence interval (CI): 0.64-0.94), IPTW-adjusted HR of 0.74 (95% CI: 0.59-0.93), RD of 12.40% (95% CI: 8.01-16.90%), IPTW-adjusted RD of 11.50% (95% CI: 7.16-15.80%), difference in restricted mean survival time (dRMST) of 12.44 (95% CI: 8.28-16.60) months, IPTW-adjusted dRMST of 7.81 (95% CI: 2.93-11.93) months, and p value of the IPTW-adjusted Log-rank test of 0.033. By interpreting BITES, the debiased impact of patient characteristics on adjuvant chemotherapy was quantified, which mainly included breast cancer subtype, tumor size, number of positive lymph nodes, TNM stages, histological grades, and surgical type.

CONCLUSION

Our results emphasize the potential of DL models in guiding adjuvant chemotherapy decisions for elderly breast cancer patients.

Contralateral prophylactic mastectomy in a rural population: A single-institution experience

Background

The incidence of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer (UBC) has continued to increase, despite an absent survival benefit except in populations at highest risk for developing contralateral breast cancer (CBC). CPM rates may be higher in rural populations but causes remain unclear. A study performed at our institution previously found that 21.8 % of patients with UBC underwent CPM from 2000 to 2009. This study aimed to evaluate the CPM trend at a single institution serving a rural population and identify the CPM rate in average-risk patients.

Methods

Retrospective review of patients who underwent mastectomies for UBC at our institution from 2017 to 2021 was performed. Analysis utilized frequencies and percentages, descriptive statistics, chi-square, and independent sample t-tests.

Results

A total of 438 patients were included, of whom 64.4 % underwent bilateral mastectomy for UBC (CPM). Patients who underwent CPM were significantly younger, underwent genetic testing, had germline pathogenic variants, had a family history of breast cancer, had smaller tumors, underwent reconstruction, and had more wound infections. Of CPM patients, 50.4 % had no identifiable factors for increased risk of developing CBC.

Conclusions

The rate of CPM in a rural population at a single institution increased from 21.8 % to 64.4 % over two decades, with an average-risk CPM rate of 50.4 %. Those that undergo CPM are more likely to undergo reconstruction and have more wound infections. Identifying characteristics of patients undergoing CPM in a rural population and the increased associated risks allows for a better understanding of this trend to guide conversations with patients.

Key message

This study demonstrates that the rate of contralateral prophylactic mastectomy for unilateral breast cancers performed at a single institution serving a largely rural population has nearly tripled over the last two decades, with half of these patients having no factors that increase the risk for developing contralateral breast cancers. Contralateral prophylactic mastectomy was significantly associated with smaller tumors, younger age, genetic testing, germline pathogenic variants, family history of breast cancer, breast reconstruction, and increased wound infections.

Patient values in breast cancer surgical decision-making - The WhySurg study

BACKGROUND

The objective of this study was to describe patient values and personality traits associated with breast surgery choice for patients with breast cancer.

METHODS

A survey based on qualitative patient interviews and the Big-Five personality trait profile was distributed to Love Research Army volunteers aged 18-70 years old who underwent breast cancer surgery from 2009 to 2020. Multivariable logistic regression analysis was used to determine independent patient values and personality traits for the choice of breast-conserving surgery (BCS), unilateral mastectomy (UM) and bilateral mastectomy (BM).

RESULTS

1497 participants completed the survey. Open-mindedness was associated with UM and sociability was associated with BM. A majority of patients prioritized cancer outcomes. Compared to BM patients, BCS and UM patients were significantly more likely to choose values associated with maintaining their self-image, optimizing surgical recovery, and following their doctor's recommendation.

CONCLUSIONS

Other values besides cancer outcomes differentiate patient surgical choice for BCS or mastectomy.

The Incidence and Outcomes of Breast Implants Among 1696 Women over more than 50 Years

OBJECTIVE

To investigate the incidence of women with breast implants in 1964-2017 MATERIALS AND METHODS: All women with breast implants in Olmsted County, MN between January 1, 1992 and December 31, 2017 were identified, and a comprehensive review of individual medical records was performed, adding to a previously identified cohort of women with breast implants in 1964-1991. Incidence rates were calculated and were age- and sex-adjusted to the US white female 2010 population.

RESULTS

In 1992-2017, 948 women with breast implants were identified, totaling 1696 Olmsted County, MN women with breast implants in 1964-2017. Overall incidence was 63.3 (95% CI 60.2-66.4) per 100,000 women, but incidence varied significantly over time. Women in 1964-1991 were more likely to have implants for cosmetic reasons and more likely to have silicone implants compared to the 1992-2017 cohort. The overall standardized mortality ratio was 1.17 (95% CI 0.99-1.38) in 1964-1991 and 0.94 (95% CI 0.66-1.29) in 1992-2017. In 1992-2017, breast reconstruction patients had a significantly elevated risk of implant rupture and implant removal versus breast augmentation patients.

CONCLUSION

The incidence of breast implants among women in Olmsted County, MN has varied drastically over the past five decades, with significant changes in the trends for implant type and reason. The findings of this study may provide further insight regarding how risks associated with implants may vary over time.

LEVEL OF EVIDENCE III

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

Cracking open the eristic rhetoric of contralateral prophylactic mastectomy research or why surgeons should not be so certain about this controversial breast cancer treatment

Contralateral prophylactic mastectomy (CPM) is a controversial breast cancer treatment in which both breasts are removed when only one is affected by cancer. Rates of CPM have been rising since the late 1990s, despite surgeons' strong agreement that the procedure should not be performed for average-risk women. This essay analyses that agreement as it is demonstrated in the surgical literature on CPM, arguing that it forms a 'rhetoric of certainty' built on the stark epistemological divide between objective and subjective forms of knowledge that operates in some areas of medicine. Further, the essay argues that this rhetoric of certainty has the potential to function as a kind of eristic rhetoric in which the right conclusion is known prior to any rhetorical exchange. As a way to 'crack open' this certainty, the essay compares the rhetoric of the surgical literature on CPM to the rhetoric of uncertainty in the radiological literature on breast cancer screening for women with a personal history of the disease. The goal of this comparison is not to suggest surgeons should support all choices for CPM. Rather, the aim is to demonstrate that choices against the procedure are not as straightforward as the surgical literature indicates and that the uncertainty affecting women's preferences for CPM is not solely the result of patient misunderstanding and/or emotional instability.

Patients' attitudes regarding genetic counseling before germline BRCA1/2 pathogenic variants testing in Taiwan: A single-country, multi-center, patient-reported outcome study

Germline pathogenic variants of BRCA1 or BRCA2 cause hereditary breast and ovarian cancer syndromes. The present study investigated the participants' understanding and awareness of germline BRCA1/2 pathogenic variants before genetic counseling, the expectations and obstacles for genetic testing from the perspective of participants and their families, and their attitudes towards genetic testing after counseling. In this single-country, multicenter, non-interventional, patient-reported outcome study, untested cancer patients and their families who visited genetic counseling clinics or who wanted to receive pre-test genetic counseling were eligible to fill in the questionnaire after pre-test counseling for germline BRCA1/2 testing. Demographic information, clinical characteristics, and information collected from the questionnaires, including the understanding of BRCA1/2 pathogenic variants before genetic counseling, understanding of BRCA1/2 pathogenic variants and feelings after genetic counseling, willingness to share results of genetic testing with family, and willingness to receive genetic testing, were summarized using descriptive statistics. A total of 88 participants were enrolled. The proportion of slight understanding of BRCA1/2 pathogenic variants increased from 11.4% to 67.0%, and the proportion of full understanding increased from 0% to 8.0%. After genetic counseling, most participants were willing to undergo genetic testing (87.5%) and share the results with their families (96.6%). The main factors that may affect participants' willingness to undergo BRCA1/2 testing were management (61.2%) and testing costs (25.9%). After pre-test counseling, there was a high acceptance of BRCA1/2 testing and in-family information sharing in Taiwanese patients with cancer and their families, which may serve as a reference for implementing genetic counseling in Taiwan.

The impact of coding germline variants on contralateral breast cancer risk and survival

Evidence linking coding germline variants in breast cancer (BC)-susceptibility genes other than BRCA1, BRCA2, and CHEK2 with contralateral breast cancer (CBC) risk and breast cancer-specific survival (BCSS) is scarce. The aim of this study was to assess the association of protein-truncating variants (PTVs) and rare missense variants (MSVs) in nine known (ATM, BARD1, BRCA1, BRCA2, CHEK2, PALB2, RAD51C, RAD51D, and TP53) and 25 suspected BC-susceptibility genes with CBC risk and BCSS. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with Cox regression models. Analyses included 34,401 women of European ancestry diagnosed with BC, including 676 CBCs and 3,449 BC deaths; the median follow-up was 10.9 years. Subtype analyses were based on estrogen receptor (ER) status of the first BC. Combined PTVs and pathogenic/likely pathogenic MSVs in BRCA1, BRCA2, and TP53 and PTVs in CHEK2 and PALB2 were associated with increased CBC risk [HRs (95% CIs): 2.88 (1.70-4.87), 2.31 (1.39-3.85), 8.29 (2.53-27.21), 2.25 (1.55-3.27), and 2.67 (1.33-5.35), respectively]. The strongest evidence of association with BCSS was for PTVs and pathogenic/likely pathogenic MSVs in BRCA2 (ER-positive BC) and TP53 and PTVs in CHEK2 [HRs (95% CIs): 1.53 (1.13-2.07), 2.08 (0.95-4.57), and 1.39 (1.13-1.72), respectively, after adjusting for tumor characteristics and treatment]. HRs were essentially unchanged when censoring for CBC, suggesting that these associations are not completely explained by increased CBC risk, tumor characteristics, or treatment. There was limited evidence of associations of PTVs and/or rare MSVs with CBC risk or BCSS for the 25 suspected BC genes. The CBC findings are relevant to treatment decisions, follow-up, and screening after BC diagnosis.

Does mainstream BRCA testing affect surgical decision-making in newly-diagnosed breast cancer patients?

BACKGROUND

Germline pathogenic variants mutations) in the BRCA1 and BRCA2 genes cause an increased risk of breast cancer and ovarian cancer. Mainstream cancer genetic testing (MCG) was introduced for breast cancer patients in our unit in 2013. Non-geneticist clinicians have been trained to offer genetic testing during initial treatment planning. We assessed the impact of timely test results on surgical decision-making.

METHODS

Women who had undergone mainstream genetic testing for breast cancer between September 2013 and September 2018 were identified from a prospective database. Surgical data were collected retrospectively.

RESULTS

580 eligible women had mainstream genetic testing. For 474 this was their first breast cancer diagnosis. The median age was 46 years (interquartile range (IQR) 38-57). The indications were: age ≤45 years for 233 (49%); triple negative disease for 192 women (40.5%); bilateral breast cancer age <60 for 39 (8%) and other for 72 (14%) women. The median time for test initiation to result was 18 days (IQR 15-21). 302 (64% received results before surgery. 88% of those found to have a BRCA mutation before surgery opted for bilateral mastectomy (compared to 5% with BRCA wild type). An additional 106 patients had a new diagnosis on a background of previous treatment. Of these all with a pathogenic variant chose bilateral mastectomy.

CONCLUSION

Timely BRCA gene testing influences surgeons' and patients' choice of surgery. It reassures women with a negative result and allows those with a positive result to take an active decision about the management of their future risk.

How Contralateral Prophylactic Mastectomy Does the Body, or Why Epistemology Alone Cannot Explain this Controversial Breast Cancer Treatment

Since the late 1990s, the use of contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer has been on the rise. Over the past two decades, dozens of studies have been conducted in order to understand this trend, which has puzzled and frustrated physicians who find it at odds with efforts to curb the surgical overtreatment of breast cancer, as well as with evidence-based medicine, which has established that the procedure has little oncologic benefit for most patients. Based on the work of Annemarie Mol and John Law, this paper argues that these efforts to understand increased CPM use are limited by the "epistemology problem" in medicine, or, in other words, the tendency to view healthcare controversies and decision making exclusively through the lenses of objective and subjective forms of knowledge. Drawing on public discourse about rationales for choosing CPM, we argue that this surgical trend cannot adequately be understood in terms of what doctors and patients know about breast cancer risk and how CPM affects that risk. In addition, it must be recognized as the outcome of how specific practices of screening, detection, and treatment do or enact the bodies of patients, producing tensions in their lives that cannot be remedied with better or better communicated information. Recognizing the embodied realities of these enactments and their effects on patient decision making, we maintain, is essential for physicians who want to avoid the paternalism that haunts breast cancer treatment in the US.

Controversies in Breast Cancer Surgery

Breast surgical oncology is a rapidly evolving field with significant advances shaped by practice-changing research. Three areas of ongoing controversy are (1) high rates of contralateral prophylactic mastectomy (CPM) in the United States despite uncertain benefit, (2) indications for and use of neoadjuvant chemotherapy (NACT) and endocrine therapy (NET), and (3) staging and treatment of the axilla, particularly after neoadjuvant systemic therapy. We discuss the patient populations for whom CPM may or may not be beneficial, indications for NACT and NET, and the trend toward de-escalation of locoregional axillary treatment.

Breast cancer characteristics and surgery among women with Li-Fraumeni syndrome in Germany-A retrospective cohort study

Background

Women with Li‐Fraumeni syndrome (LFS) have elevated breast cancer (BC) risk. Optimal BC treatment strategies in this population are yet unknown.

Methods

BC subtypes and treatment were retrospectively investigated between December 2016 and January 2019 in a multicentre study. BC risks were evaluated according to the type of surgery.

Results

Thirty‐five women of our study population (35/44; 79.5%) had developed 36 breast lesions at first diagnosis at a mean age of 34 years. Those breast lesions comprised 32 invasive BCs (89%), three ductal carcinoma in situ alone (8%) and one malignant phyllodes tumour (3%). BCs were mainly high‐grade (18/32), of no special type (NST; 31/32), HER2‐enriched (11/32) or luminal‐B‐(like)‐type (10/32). Affected women (n = 35) received breast‐conserving surgery (BCS, n = 17) or a mastectomy (ME, n = 18) including seven women with simultaneous contralateral prophylactic mastectomy (CPM) at first diagnosis. Nineteen women suffered 20 breast or locoregional axillary lesions at second diagnosis with mean age of 36. Median time between first and second diagnosis was 57 months; median time to contra‐ and ipsilateral recurrence depended on surgical strategies (BCS: 46 vs. unilateral ME: 93 vs. bilateral ME > 140 months). Women with a primary treatment of solitaire therapeutic ME suffered from contralateral BC earlier compared to those with therapeutic ME and CPM (median: 93 vs. >140 months).

Conclusion

Aggressive BC subtypes occur among women with LFS. Surgical treatment, i.e. ME and CPM, may prolong time to a second BC diagnosis. Conclusion on long‐term survival benefit is pending. Individual competing tumour risks and long‐term outcomes need to be taken into consideration.

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

Background

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

Methods

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

Results

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

Conclusions

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

Influencers of the Decision to Undergo Contralateral Prophylactic Mastectomy among Women with Unilateral Breast Cancer

Simple Summary

In this survey study, we examined survey responses from 397 women with stage 0 to III unilateral breast cancer and found that partners, physicians, and the media were significant relative to the patient’s own influence in their decision to undergo a CPM. The findings of this study may inform policy by highlighting the need for educational aids, programs, or tools that help women with unilateral breast cancer make informed, evidence-based decisions regarding CPM efficacy.

Abstract

(1) Background: The relatively high rate of contralateral prophylactic mastectomy (CPM) among women with early stage unilateral breast cancer (BC) has raised concerns. We sought to assess the influence of partners, physicians, and the media on the decision of women with unilateral BC to undergo CPM and identify clinicopathological variables associated with the decision to undergo CPM. (2) Patients and Methods: Women with stage 0 to III unilateral BC who underwent CPM between January 2010 and December 2017. Patients were surveyed regarding factors influencing their self-determined decision to undergo CPM. Partner, physician, and media influence factors were modeled by logistic regressions with adjustments for a family history of breast cancer and pathological stage. (3) Results: 397 (29.6%) patients completed the survey and were included in the study. Partners, physicians, and the media significantly influenced patients’ decision to undergo CPM. The logistic regression models showed that, compared to self-determination alone, overall influence on the CPM decision was significantly higher for physicians (p = 0.0006) and significantly lower for partners and the media (p < 0.0001 for both). Fifty-nine percent of patients’ decisions were influenced by physicians, 28% were influenced by partners, and only 17% were influenced by the media. The model also showed that patients with a family history of BC had significantly higher odds of being influenced by a partner than did those without a family history of BC (p = 0.015). (4) Conclusions: Compared to self-determination, physicians had a greater influence and partners and the media had a lower influence on the decision of women with unilateral BC to undergo CPM. Strong family history was significantly associated with a patient’s decision to undergo CPM.

A Tale of Two Sisters: Breast Reconstruction Options for Women With or at High Risk of Breast Cancer

Breast reconstructive surgery has changed significantly over the past decade. The incidence of nipple-sparing procedures and prophylactic mastectomy has also increased significantly as women and their surgeons use shared decision-making strategies. The following case history of two sisters, one with breast cancer and one at elevated risk for breast cancer, highlights the current standard of care with newer gold-standard procedures for mastectomy and subsequent reconstruction. A comparison of types of mastectomies, steps in reconstruction, and reconstruction options are discussed.

Increasing Role of Oncoplastic Surgery for Breast Cancer

PURPOSE OF REVIEW

The goals of surgery for breast cancer have remained the same over the years, to eliminate breast cancer from the breast with the least degree of deformity. With the current expectation of long-term survival after breast cancer treatment, more attention has turned to the cosmetic result of the surgical treatment. Whether lumpectomy or mastectomy, the need for aesthetic improvement was recognized by surgeons both in and outside the USA.

RECENT FINDINGS

Oncoplastic surgery combines the skills of the cancer surgeon with those of the plastic surgeon. Sometimes, this means a team approach with a breast surgeon and a plastic surgeon both performing their mutual skills for the patient. Other times, the properly trained breast surgeon may perform some of the plastic techniques at the time of cancer surgery. Breast surgeons are rapidly gaining the ability to improve the post-cancer treatment appearance. To simplify the classification of oncoplastic techniques, we have used lower level, upper level, and highest level. The assignment of techniques to levels is based on both the technique and the surgeon's training and experience. Much data has accumulated demonstrating the safety and efficacy of the "aesthetic cancer cure." We describe the development of oncoplastic surgery, the techniques available, matching the right candidate with the right technique, and some comments about the future. It is clear from both clinical benefit and patient satisfaction that oncoplastic breast cancer procedures are here to stay. Plastic surgeons will likely focus on the upper- and highest-level procedures while breast/general surgeons will learn lower-level procedures and some of upper-level procedures as needed by their locale. Opportunities to educate breast/general surgeons in these techniques will continue to increase over the next several years. Formal education in oncoplastic surgery during breast fellowships will be necessary to catch up with the rest of the surgical world outside the USA.

Preventive drug therapy and contralateral breast cancer: summary of the evidence of clinical trials and observational studies

Background: Breast cancer patients have a lifelong 2-4-fold increased risk of developing a second primary tumor in the contralateral breast compared with the risk for a first primary breast cancer in the general female population. Prevention of contralateral breast cancer (CBC) has received increased attention during recent decades. Here, we summarize and discuss the available literature on drug preventive therapy and CBC.Results: The endocrine-targetting drugs, tamoxifen and aromatase inhibitors are used as standard adjuvant treatment for estrogen receptor (ER)-positive breast cancer. Both are associated with relative risk reductions of CBC of up to 50%, but incur serious side effects. Several prescription drugs originally developed for other purposes, including bisphosphonates, statins, non-steroidal anti-inflammatory drugs, metformin, anti-hypertensives and retinoids, have shown anti-cancer activity in preclinical models. However, results of observational studies on CBC are sparse and inconsistent, with only statins demonstrating promise as preventive agents and a potential treatment option for ER-negative breast cancer patients.Conclusion: Future studies are needed to assess the effect of statins in risk reduction and to identify other drugs with chemopreventive potential against CBC. Eventually, efforts must be directed towards identifying those breast cancer patients likely to benefit most from specific preventive therapies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Upper extremity disability and quality of life after breast cancer treatment in the Greater Plains Collaborative clinical research network

PURPOSE

Chronic upper extremity disability (UED) is common after breast cancer treatment but under-identified and under-treated. Although UED has been linked to quality of life (QoL), the role of UED as mediator between contemporary treatment practices and QoL has not been quantified. This investigation describes UED in a contemporary sample of breast cancer patients and examines its relationship with personal and treatment factors and QoL.

METHODS

Eight hundred and thirty-three women diagnosed at eight medical institutions during 2013-2014 with microscopically confirmed ductal carcinoma in situ or invasive stage I-III breast cancer were surveyed an average of 22 months after diagnosis. UED was measured with a modified QuickDASH and QoL with the FACT-B. The questionnaire also collected treatments, sociodemographic information, comorbidity, body mass index, and a 3-item health literacy screener.

RESULTS

Women who received post-mastectomy radiation and chemotherapy experienced significantly worse UED and QoL. Women who had lower income, lower health literacy and prior diabetes, arthritis or shoulder diagnoses had worse UED. Patients with worse UED reported significantly worse QoL. Income and health literacy were independently associated with QoL after adjustment for UED but treatment and prior conditions were not, indicating mediation by UED. UED mediated 52-79% of the effect of mastectomy-based treatments on QoL as compared with unilateral mastectomy without radiation. UED and QoL did not differ by type of axillary surgery or post-mastectomy reconstruction.

CONCLUSIONS

A large portion of treatment effect on QoL is mediated by UED. Rehabilitation practices that prevent and alleviate UED are likely to improve QoL for breast cancer survivors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Socioeconomic Factors Associated with the Receipt of Contralateral Prophylactic Mastectomy in Women with Breast Cancer

Background: Contralateral prophylactic mastectomy (CPM) treatments have been on the rise among white women with early stage unilateral breast cancer who have a higher socioeconomic status (SES) and private insurance. Low income and uninsured women are not choosing CPM at the same rate. The purpose of this study was to evaluate the socioeconomic factors related to the choice of surgical treatment in women diagnosed with unilateral breast cancer in the state of New Jersey. Materials and Methods: This retrospective study of 10 years of breast cancer data abstracted from the New Jersey State Cancer Registry utilized bivariate analyses and two multivariate logistic regression models to analyze the effect of socioeconomics on choice of surgical treatment. Results: In New Jersey, 52,529 women were treated for breast cancer from 2004 to 2014. CPM rates increased gradually over time from 3.72% in 2004 to 10.82% in 2014 with women more likely to choose CPM if they were younger, white, and had private insurance (p < 0.001). The single factor that was most predictive of choosing CPM was access to immediate reconstruction (odds ratio 2.36, confidence interval 2.160-2.551). Women with low SES were much less likely to choose CPM. Conclusions: Results of this study may provide incentive for researchers to assess the impact of culture, race/ethnicity, and socioeconomics on a woman's interactions with health care providers so as to allow all women regardless of SES to express their needs, concerns, and wishes when confronted with a breast cancer diagnosis.

Factors associated with decision to undergo contralateral prophylactic mastectomy versus unilateral mastectomy

BACKGROUND

Factors associated with the decision to pursue unilateral mastectomy (UM) versus contralateral prophylactic mastectomy (CPM) in unilateral breast cancer (UBC) patients, and satisfaction with this decision, remain to be elucidated.

METHODS

UBC patients who underwent mastectomy were surveyed regarding factors affecting their surgical decision and satisfaction with the same.

RESULTS

Both UM (n = 46) and CPM (n = 55) patients were satisfied with their surgical decision (mean 4.72 and 4.85 out of 5 on Satisfaction With Decision scale, respectively, p = 0.078). Most CPM patients cited the desire to lower their risk of contralateral breast cancer (96.4%) and the desire for peace of mind (94.5%) as "very important" drivers of their decision; whereas most UM patients felt not wanting to remove a normal breast (67.4%) was a "very important" driver for their decision.

CONCLUSIONS

Both UM and CPM patients reported high satisfaction with their surgical decisions, despite differing reasons for their respective surgeries.

Surgery for BRCA, TP53 and PALB2: a literature review

Introduction

The presence of a deleterious mutation, most commonly a BRCA mutation, has a tremendous impact on the management of breast cancer. We review the surgical management of BRCA mutation carriers, and two other potentially high-risk mutations, TP53 and PALB2.

Methodology

A search was done on PubMed, limited to reviews and the English language only. The search terms used were ‘BRCA’ or ‘PALB2’ or ‘TP53’ and ‘surgery’. Fifteen articles were identified by searching and one article was obtained from other sources.

Results

Breast-conserving surgery has equivalent survival, but may have an increased risk of local recurrence, compared to mastectomy among BRCA mutation carriers. Contralateral prophylactic mastectomy may not improve overall survival, despite reducing the risk of developing contralateral breast cancer. The use of preoperative genetic testing allows patients to have combined curative and prophylactic surgery. However, preoperative genetic testing may influence patients to make rash decisions. In healthy BRCA mutation carriers, bilateral prophylactic mastectomy is done to prevent breast cancer from occurring. Bilateral prophylactic mastectomy is highly effective in reducing the risk of breast cancer in healthy BRCA mutation-positive women and may have a survival benefit. Prophylactic oophorectomy reduces the risk of ovarian cancer, but may not have an effect on the risk of breast cancer. There is a lack of studies on surgery for non-BRCA mutations. TP53 and PALB2 are potentially high-risk mutations for breast cancer, which may justify the use of prophylactic surgery. Advice should be given on a case-by-case basis.

Conclusion

A comprehensive approach is needed to provide optimum treatment for breast cancer patients with deleterious mutations.

Cost-effectiveness Analysis of Contralateral Prophylactic Mastectomy Compared to Unilateral Mastectomy with Routine Surveillance for Unilateral, Sporadic Breast Cancer

BACKGROUND

Contralateral prophylactic mastectomy (CPM) rates in younger women with unilateral breast cancer have more than doubled. Studies of cost and quality of life of the procedure remain inconclusive.

METHODS

A cost-effectiveness analysis using a decision-tree model in TreeAge Pro 2015 was used to compare long-term costs and quality of life following unilateral mastectomy (UM) with routine surveillance versus CPM for sporadic breast cancer in women aged 45 years. A 10-year risk period for contralateral breast cancer (CBC), reconstruction, wound complications, cost of routine surveillance, and treatment for CBC were used to estimate accrued costs. In addition, a societal perspective was used to estimate quality-adjusted life years (QALYs) following either treatment for a period of 30 years. Medical costs were obtained from the 2014 Medicare physician fee schedule and event probabilities were taken from recent literature.

RESULTS

The mean cost of UM with surveillance was $14,141 and CPM was $20,319. Treatment with CPM resulted in $6178 more in costs but equivalent QALYs (17.93) compared with UM over 30 years of follow-up. Even with worst-case scenario and varying assumptions, CPM is dominated by UM in terms of cost and quality.

CONCLUSIONS

From this refined model, UM with routine surveillance costs less and provides an equivalent quality of life. Patients undergoing CPM may eliminate the anxiety of routine surveillance, but they face the burden of higher lifetime medical costs.

Mortality after contralateral breast cancer in Denmark

PURPOSE

How a second breast cancer diagnosis affects survival in comparison with unilateral breast cancer (UBC) is unclear. Prognostic factors for contralateral breast cancer (CBC) are also not well established. We aimed to investigate the survival pattern after CBC with particular focus on time between first and second breast cancer diagnosis and age at CBC diagnosis.

METHODS

Within the nationwide Danish Breast Cancer Cooperative Group database, we identified 68,466 breast cancer patients diagnosed during 1978-2012. Patients who subsequently developed CBC were identified in a previously established database (N = 3004). Patients were followed for breast cancer-specific death in the Danish Register of Causes of Death until 2015. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazard regression models. Cumulative breast cancer mortality from date of CBC was estimated using the Aalen-Johansen method.

RESULTS

Compared with UBC patients, the rate of dying from breast cancer was more than twofold higher following a CBC diagnosis, after adjustment for age, period, tumor characteristics, and treatment of the first breast cancer (HR 2.48; 95% CI 2.31-2.66). Short time interval (< 5 years) was associated with higher breast cancer-specific mortality after CBC among patients < 70 years at CBC diagnosis compared with longer time intervals, but not among patients ≥ 70 years at CBC diagnosis.

CONCLUSION

Breast cancer-specific mortality rates were markedly higher after compared with before a CBC diagnosis. We found higher breast cancer-specific mortality after CBC associated with a short interval between diagnoses among patients diagnosed with CBC before age 70 years.

Breast Cancer Genetics and Indications for Prophylactic Mastectomy

As more genetic information becomes available to inform breast cancer treatment, screening, and risk-reduction approaches, clinicians must become more knowledgeable about possible genetic testing and prevention strategies, including outcomes, benefits, risks, and limitations. The aim of this article is to define and distinguish high- and moderate-risk breast cancer predisposition genes, summarize the clinical recommendations that may be considered based on the identification of pathogenic variants (mutations) in these genes, and indications for risk-reducing and contralateral prophylactic mastectomy.

Risk-reducing mastectomy for the prevention of primary breast cancer

BACKGROUND

Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010.

OBJECTIVES

(i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH METHODS

For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English.

SELECTION CRITERIA

Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer.

DATA COLLECTION AND ANALYSIS

At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias.

MAIN RESULTS

All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM.

AUTHORS' CONCLUSIONS

While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.

Trends in breast reconstruction practices in a specialized breast tertiary referral centre

BACKGROUND

Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population.

METHODS

Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy.

RESULTS

Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy.

CONCLUSION

Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

Commentary on the Consensus Statement of the American Society of Breast Surgeons on Contralateral Prophylactic Mastectomy

The increasing rate of contralateral prophylactic mastectomy (CPM) led the American Society of Breast Surgeons (ASBrS) to issue an evidence-based consensus statement on CPM, as well as a discussion guide that health care providers can use to facilitate shared decision making with patients considering CPM for unilateral breast cancer. This article suggests several ways to improve the discussion guide by eliciting patient values and preferences and by providing more current, detailed, and balanced information about the potential risks and benefits of CPM.