The woman at increased risk for breast cancer: evaluation and management strategies

Enhancing breast cancer treatment: mesoporous dopamine nanoparticles in synergy with chrysin for photothermal therapy

Introduction

Breast cancer is one of the most prevalent cancers, primarily affecting women. Among its subtypes, estrogen receptor-positive (ER+) breast cancer is particularly common. Inhibiting estrogen's effects is crucial for treating ER+ breast cancer, but current therapies often have significant side effects and limitations. Chrysin, a natural flavonoid, has shown potential in reducing estrogen receptor expression, but its poor water solubility hampers clinical application. This study explores the use of mesoporous dopamine nanoparticles (mPDA) to enhance the delivery and efficacy of Chrysin, combined with photothermal therapy (PTT), for breast cancer treatment.

Methods

Chrysin-loaded mPDA nanoparticles (Chrysin@mPDA) were synthesized and characterized for their morphology, drug-loading efficiency, stability, and photothermal properties. Network pharmacology was used to predict Chrysin's mechanisms in breast cancer, which were validated through gene expression analysis in cell experiments. The therapeutic efficacy of Chrysin@mPDA with and without PTT was evaluated in a mouse model of breast cancer, with tumor volume and weight measured. Immunohistochemical analysis was conducted to assess estrogen receptor expression and immune cell infiltration in tumor tissues.

Results

Chrysin@mPDA nanoparticles demonstrated a high drug-loading capacity and excellent stability. Photothermal studies confirmed the nanoparticles' ability to generate heat upon laser exposure, significantly enhancing Chrysin release in acidic conditions with laser irradiation. Network pharmacology identified key target genes affected by Chrysin, including ESR1, BRCA1, CTNNB1, and BAX, which were validated through qPCR. In vivo, the combination of Chrysin@mPDA and PTT significantly reduced tumor volume and weight, decreased estrogen receptor-positive cells, and increased infiltration of CD3+CD4+ and CD3+CD8+ T cells in tumor tissues.

Discussion

The study highlights the potential of Chrysin-loaded mPDA nanoparticles combined with PTT as an effective strategy for breast cancer treatment. This approach addresses the limitations of Chrysin's solubility and enhances its therapeutic efficacy through synergistic mechanisms. The dual action of Chrysin in modulating gene expression and PTT in inducing localized hyperthermia and immune response suggests a promising avenue for improved breast cancer prognosis and reduced recurrence.

ZBTB28 inhibits breast cancer by activating IFNAR and dual blocking CD24 and CD47 to enhance macrophages phagocytosis

Breast cancer is the leading cause of cancer death in female. Until now, advanced breast cancer is still lack effective treatment strategies and reliable prognostic markers. In the present article, we introduced the physiologic and pathologic functions and regulation mechanisms of ZBTB28, a tumor suppressor gene, in breast cancer. ZBTB28 is frequently silenced in breast cancer due to promoter CpG methylation, and its expression is positively correlated with breast cancer patient survival. The antineoplastic effect of ZBTB28 in breast cancer was elucidated through a series of in vitro and in vivo measurements, including cell proliferation, apoptosis, cell cycle, epithelial mesenchymal transition (EMT), and growth of xenografts. Furthermore, ZBTB28 can directly regulate IFNAR to activate interferon-stimulated genes and potentiate macrophage activation. Ectopic ZBTB28 expression in breast cancer cells was sufficient to downregulate CD24 and CD47 to promote phagocytosis of macrophages, demonstrating that ZBTB28 was beneficial for the combination treatment of anti-CD24 and anti-CD47. Collectively, our results reveal a mode of action of ZBTB28 as a tumor suppressor gene and suggest that ZBTB28 is an important regulator of macrophage phagocytosis in breast cancer, holding promise for the development of novel therapy strategies for breast cancer patients.

Identifying women with increased risk of breast cancer and implementing risk-reducing strategies and supplemental imaging

Breast cancer (BC) is the second most common cancer in women, affecting 1 in 8 women in the United States (12.5%) in their lifetime. However, some women have a higher lifetime risk of BC because of genetic and lifestyle factors, mammographic breast density, and reproductive and hormonal factors. Because BC risk is variable, screening and prevention strategies should be individualized after considering patient-specific risk factors. Thus, health care professionals need to be able to assess risk profiles, identify high-risk women, and individualize screening and prevention strategies through a shared decision-making process. In this article, we review the risk factors for BC, risk-assessment models that identify high-risk patients, and preventive medications and lifestyle modifications that may decrease risk. We also discuss the benefits and limitations of various supplemental screening methods.

Assessment of Human Papillomavirus Infection and Risk Factors in Egyptian Women With Breast Cancer

Numerous risk factors for breast cancer (BC) have been identified. High-risk human papilloma virus (HR-HPV) is the etiological agent of cervical cancer and in some cases of head and neck cancer, specifically oropharyngeal cancer, but the role of HR-HPV in evoking neoplasia in BC is still unclear. In this study, all women above the age of 18 visiting the oncology clinic at Al-Azhar university hospital and Ain Shams specialized hospital between the period of February 2017 and March 2018 were invited to participate. We determined the prevalence of HR-HPV genotypes 16, 18, and 31 in breast tissue samples from 72 women with treatment-naïve BC and 15 women with benign breast lesions (BBL) by quantitative real-time PCR (qRT-PCR) and primer sets targeting the E6 and E7 regions. High-risk human papilloma virus DNA was detected in 16 of 72 (22.2%) BC cases (viral load range = 0.3-237.8 copies/uL) and 0 of 15 women with BBL. High-risk human papilloma virus was detected in 14 of 16 (87.5%), 2 of 16 (12.5%), and 0 of 16 (0%) for genotypes 16, 18, and 31, respectively. Forty-three age-matched healthy Egyptian women were enrolled as controls for assessment of local risk factors that can be used to initiate a strategy of BC prevention in Egypt. Assessment of the risk factors demonstrated that low education level, passive smoking, lack of physical activity, family history of cancer, and use of oral contraception were significant risk factors for BC. In conclusion, our results lead us to postulate that HR-HPV infection may be implicated in the development of some types of BC in Egyptian women. In addition, identification of local risk factors can support practical prevention strategies for BC in Egypt.

Evaluation of Common Risk Factors for Breast Carcinoma in Females: a Hospital Based Study in Karachi, Pakistan

BACKGROUND

Breast malignancies are one of the leading causes of deaths in females worldwide. There are a number of risk factors associated with breast cancer but in Karachi Pakistan there are insufficient data available.

MATERIALS AND METHODS

A case control study was conducted on females in age group between 30-80 years. This study was accomplished by retrospective data collection in Aga Khan University Hospital Karachi, Pakistan. A total of 108 females with primary malignancy of breast were included along with 108 matched controls. Relationship of various factors with disease was studied using logistic regression to calculate odds ratios with 95 % confidence intervals.

RESULTS

A total of 14 variables were analyzed and based on and 7 were found to be risk factors: old age, family history of breast cancer, family history of other carcinomas, personal history of breast carcinoma, early age of menarche, older age of mother at first delivery and lower number of children. Five factors, parity, breast feeding, history of oral contraceptive pills intake, past history of oophorectomy and hysterectomy showed protective associations. One variable, use of hormonal replacement therapy, showed a controversial link and one other, marital status, was not significant in this study.

CONCLUSIONS

It is concluded that most of the well-known risk factors for breast cancer are also associated with the disease in the female population of Karachi, Pakistan. High risk patients should be the focus with the help of this study so that screening can be more effective for early diagnosis before clinically evident breast malignancy.

Breast cancer after prophylactic mastectomy (bilateral or contralateral prophylactic mastectomy), a clinical entity: presentation, management, and outcomes

Contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) markedly decrease the possibility of new breast cancer (BC) ipsilateral to the prophylactic mastectomy (PM). Given its relative infrequency, little is known about the clinical characteristics, presentation, and management of BC after PM. Between 1960 and 1993, 1065 women underwent BPM and 1643 women with unilateral BC treated with therapeutic mastectomy underwent CPM at our institution. Medical records were reviewed, and study-specific questionnaires were sent to all women. BC after PM included locoregional invasive BC or ductal carcinoma in situ ipsilateral to the PM. BC developed ipsilateral to the PM in 25 patients (13 after BPM; 12 after therapeutic mastectomy and CPM). Median follow-up after PM was 22 years (range 3-34 years). Presentations included clinically isolated local disease in 17 patients (68%); disease limited to the axilla without evidence of local primary disease in 4 (16%); synchronous local and axillary disease in 1 (4%); and synchronous local disease and distant metastases in 3 (12%). The 17 patients presenting with isolated local disease were most commonly managed with completion or redo mastectomy (65%) or local excision (29 %), followed by consideration of adjuvant therapy. The 5-year disease-free survival estimate was 69% (95% CI 52-94%) for the 22 patients who had isolated locoregional BC after PM and were treated with curative intent. Although rare, BC after PM can occur. The most common presentation, disease localized to the mastectomy site, can be managed with resection and consideration of adjuvant therapy.

Variants of uncertain significance in BRCA testing: evaluation of surgical decisions, risk perception, and cancer distress

Studies suggest that patients carrying a BRCA variant of uncertain significance (VUS) may have lingering confusion concerning results interpretation. Counseling for uninformative BRCA-negative (UN) results is thought to be more straightforward, despite the fact that both results lead to similar methods of empiric cancer risk counseling. This study compared surgical choices and perceptions between 71 patients with VUS results and 714 patients with UN results. All patients underwent genetic counseling because of a personal or family history of breast or ovarian cancer between 1997 and 2010, and completed a 2-year follow-up survey. Risk-reducing mastectomy rates in both groups were 7% (p = 1.00) and risk-reducing oophorectomy rates were 5% and 3%, respectively (p = 0.42). The VUS group reported less cancer distress reduction than the UN group (23.0% vs 35.8%, respectively, p = 0.043). Over 90% of both groups found the counseling process helpful. Overall, the study suggests that VUS results disclosed in genetic counseling did not cause excessive surgery or exaggerated cancer distress, though patients with a VUS found counseling somewhat less informative or reassuring. Future research on communication of VUS results, including pre-and post-test counseling, is essential for full realization of the potential for genomic medicine.

Routine prophylactic sentinel lymph node biopsy is not indicated in women undergoing prophylactic mastectomy

BACKGROUND

Prophylactic mastectomies (PM) are performed to reduce the risk of breast cancer. Occasionally an occult carcinoma is found in PM specimens. Given the high morbidity of axillary lymph node dissection (ALND), some perform prophylactic sentinel lymph node biopsy (SLNB). We undertook a study to examine if prophylactic SLNB is indicated in all patients undergoing PM.

METHODS

A retrospective review of all PM between 2004 and 2010 was performed. The stage of tumor on the disease side and the pathologic findings in the prophylactic breast were analyzed. The number of SLN and the frequency of lymph node metastases were evaluated.

RESULTS

A total of 199 PM on 184 patients were performed: 169 contralateral PM and 30 bilateral PM. Of the 199 PM, 12 had occult carcinomas (6.0%): 10 non-invasive, 1 microinvasive and 1 T1b invasive tumor. 153 of 199 PM specimens had prophylactic SLNB, of which only 2 had a positive SLN that originated from the index side of the breast.

CONCLUSIONS

Although it is not uncommon to find occult carcinomas in the prophylactic breast, it is rare for the occult carcinoma to spread to the lymph nodes. Therefore, routine prophylactic SLNB is not indicated in patients undergoing PM.

Male breast cancer

Male breast cancer (MBC) is a rare disease. However, as global populace ages, there is a trend to MBC increasing. Although aetiology is still unclear, constitutional, environmental, hormonal (abnormalities in estrogen/androgen balance) and genetic (positive family history, Klinefelter syndrome, mutations in BRCA1 and specially BRCA2) risk factors are already known. Clinic manifestation is painless hard and fixed nodule in the subareolar region in 75% of cases, with nipple commitment earlier than in women. Breast cancer has similar prognostic factors in males and females, among which axillary adenopathy (present in 40-55% cases) is the most important one. Although mammography, ultrasonography and scintigraphy can be useful tools in diagnosis; clinical assessment, along with a confirmatory biopsy, remains the main step in the evaluation of men with breast lesions. Infiltrating ductal carcinoma is the most frequent histological type. The established standard of care is modified radical mastectomy followed by tamoxifen for endocrine-responsive positive disease, although other options are being explored. While similarities between breast cancer in males and females exist, it is not appropriate to extrapolate data from female disease to the treatment of male. There is a need for specific multi-institutional trials to better understanding of clinicopathologic features and establishment of optimal therapy for this disease.

The History of Mastectomy

The mastectomy that is performed today is a procedure born from hundreds of years of discoveries, inventions, and amendments to existing surgical techniques. The reasons for performing this extreme surgery have changed as well, ranging from unilateral breast removal to allow greater upper limb functionality to bilateral removal of the breasts or breast tissue in individuals predisposed to breast cancer or in individuals who have already been diagnosed. The additions of surgical tools and anesthetics to the field of medicine further transformed the surgical field in general and had a large impact on the mastectomy. William Halsted's radical mastectomy served as the basis of most future breast removal techniques, and it the method recognized today as the “radical mastectomy.” Most radical surgeries are currently used for prophylaxis, whereas less invasive lumpectomies have eclipsed breast removal surgeries as of the latter half of the 20th century.

A two-center study of Muslim women's views of breast cancer and breast health practices in Pakistan and the UK

Breast health awareness practices of Pakistani Muslim women in the UK and Pakistan is unknown. Focus group interviews were used to investigate the impact of culture and psychosocial issues on breast health awareness involving 44 women in Lahore and London. Women based in Lahore were more inquisitive about breast cancer and held more developed views compared with British Pakistani Muslim women. Women concurred that concise and relevant breast health education is needed irrespective of faith to improve cultural sensitivity and awareness in both Pakistani communities (both men and women).

Australian women's awareness of breast cancer symptoms and responses to potential symptoms

OBJECTIVES

Poor awareness of breast cancer symptoms has been associated with patient delay in seeking help; thus reduced survival, more aggressive treatment, and fewer treatment choices. The aim of this study was to develop a representative picture of Australian women's knowledge of symptoms, experienced potential symptoms, and behavioral responses.

METHODS

A general population sample of approximately 3,000 women aged 30-69 completed a telephone survey; results were compared to previous surveys conducted in 1996 and 2003.

RESULTS

The most commonly cited potential symptom of breast cancer was a lump in the breast, identified by 86% of respondents (an increase from 75% in 2003). Other commonly mentioned symptoms were discharge from the nipple, pain/soreness, skin puckering, or dimpling; and a change in breast shape. The proportion unable to name any potential symptoms of breast cancer decreased from one in ten in 2003 to approximately one in twenty in 2007. The primary reason for not seeking medical advice in response to a potential symptom was the belief that breast cancer was not present.

CONCLUSIONS

Health promotion efforts need to continue to aim at increasing community understanding of potential breast cancer symptoms and encouraging women to act on potential symptoms by seeking medical advice.

Assessing breast cancer risk and providing treatment recommendations: immediate impact of an educational session

The widespread availability of information regarding advancements in breast cancer care has heightened public awareness about risk and prevention, but there is limited knowledge as to the translation of these evolving advancements into physician practice patterns. The purpose of this study was to: (a) determine current practice patterns/treatment recommendations for evaluating patients at high-risk for breast cancer and (b) measure the immediate effect of an educational session on new knowledge acquired for high-risk patients. Five thousand and one health care provider surveys were sent to physicians in the greater Chicago area. The survey inquired about practice patterns and offered an opportunity to attend an educational session utilizing our "Spectrum of Care Options" framework. To evaluate session effectiveness, pre and post-tests were administered to participants. Of 767 survey respondents, 78 attended an educational session, 64 completed a pre and post-test, and 65 completed program evaluations. Pretest scores averaged 67.1% correct (range = 29-100%, SD = 15.8%) while post-test scores averaged 80.3% correct (range = 59-100%, SD = 11.0%), p < 0.0001. Participants rated the following on a 1-5 (poor to excellent) Likert scale (average scores): presentations 4.74, instructional materials 4.58, usefulness to practice 4.60, new knowledge gained 4.71, and likelihood of changing practice 4.49. Primary care physicians and surgeons are interested in identifying and treating high-risk patients, but may lack sufficient state-of-the art knowledge to do so. An educational session providing information on this subject, based on Spectrum of Care Options, significantly improved their knowledge and may influence their future practices.

Contralateral risk-reducing mastectomy in young breast cancer patients with and without genetic cancer risk assessment

BACKGROUND

Decisions regarding contralateral risk-reducing mastectomy (CRRM) among women diagnosed with unilateral breast cancer can potentially be influenced by age at diagnosis and other factors. In this study, we examined the use of CRRM before versus after genetic cancer risk assessment (GCRA) in women diagnosed with breast cancer before age 50.

METHODS

We conducted a retrospective analysis of women with invasive breast cancer diagnosed before age 50 who were seen for GCRA between October 1996 and March 2005. Associations between the presence of generally accepted indications for risk-reducing surgery among women who had CRRM and the timing of GCRA were examined.

RESULTS

The cohort included 378 women, of whom 57 had CRRM pre-GCRA and 45 had CRRM post-GCRA after a median follow-up of 26 months. Women who had CRRM pre-GCRA were more likely to not have a generally accepted indication for the procedure than those who did after GCRA (odds ratio [OR] 5.3, 95% confidence interval [95% CI] 1.6-17.8, P = .007). Women diagnosed with breast cancer before BRCA genetic testing became clinically available (1997) were more likely to have had CRRM pre-GCRA than those who were diagnosed more recently (OR 2.9, 95% CI 1.6-5.2, P = .0003).

CONCLUSION

When personal and family history was carefully examined, a substantial proportion of women seen in our clinic did not have a clear indication for CRRM. Decreased use of empiric CRRM among women diagnosed after 1997 may indicate increased awareness and use of GCRA. Thus, judicious application of GCRA may help focus use of surgical risk reduction measures to the most risk-appropriate patients.

Expression of selected Aurora A kinase substrates in solely estrogen-induced ectopic uterine stem cell tumors in the Syrian hamster kidney

Sustained over-expression of Aurora A (AurA), centrosome amplification, chromosomal instability, and aneuploidy are salient features that occur in high frequency in human breast premalignant stages and in primary ductal breast cancer (BC), as well as in 17beta-estradiol (E2)-induced oncogenesis in animal models. We have reported that AurA/B protein expression increases 8.7- and 4.6-fold, respectively, in primary E2-induced male Syrian hamster uterine stem cell-like tumors of the kidney (EUTK) when compared with cholesterol-treated control kidneys. Upon a 10-day E2-withdrawal or coadministration of tamoxifen citrate, a 78-79% and 81-64% reduction in AurA/B protein expression, respectively, were observed in primary tumors when compared with tumors from animals continuously exposed to E2. These data indicate that AurA/B expression is regulated by estrogens via estrogen receptor alpha. To determine whether this E2-induced over-expression of the Aur kinases may contribute to the alterations observed during oncogenesis via their phosphorylation of specific substrates, we analyzed the protein expression of histone H3 and targeting protein for Xklp2 (TPX2). Histone H3 and TPX2 were significantly over-expressed 3.7- and 1.6-fold, respectively, in E2-induced tumors when compared with cholesterol-treated control kidney samples. Immunohistochemistry revealed that TPX2 protein expression was essentially confined to tumor foci cells. Collectively, these data indicate that over-expression of AurA/B is under estrogen control and that the deregulation of Aur kinase protein substrates is implicated in eliciting the alterations observed during oncogenesis.

Is Routine Sentinel Lymph Node Biopsy Indicated in Women Undergoing Contralateral Prophylactic Mastectomy? Magee-Womens Hospital Experience

INTRODUCTION

The routine use of sentinel node biopsy (SLNB) at the time of prophylactic mastectomy remains controversial. This retrospective study was undertaken to determine if SLNB is justified in patients undergoing CPM.

METHODS

Between 1999 and 2004, 155 patients underwent contralateral prophylactic mastectomy (CPM) at the Magee-Womens Hospital of University of Pittsburgh Medical Center. Eighty patients (51.6%) had SLNB performed at the time of CPM. The therapeutic mastectomy and the CPM specimens were evaluated for histopathology. Goldflam's classification was used to determine the risk of malignancy in the CPM specimens.

RESULTS

Pathology in the therapeutic mastectomy specimens included 105 (68%) invasive carcinomas and 50 (32%) in-situ carcinomas. Multicentricity and/or multifocality were reported in 49.7%, and 70% were estrogen receptor positive. Two invasive breast cancers and three cases of DCIS were diagnosed in 155 CPM specimens (n = 5, 3.2%). The median number of SLN identified was 2 (range 1-6) from the CPM axilla. Two patients had positive SLNB for metastatic carcinoma (n = 2/80, 2.5%) with no primary tumor identified in the prophylactic mastectomy specimen. In both patients the therapeutic mastectomy was for recurrent invasive carcinoma in patients with a prior history of axillary node dissection. Occult carcinoma was found in five prophylactic mastectomy specimens: two invasive and three DCIS. Only 1 out of the 75 patients not undergoing SLNB at the time of their initial surgery would have required axillary staging for a previously undiagnosed invasive cancer in the CPM specimen on final pathology. Of all 155 patients undergoing CPM, only 4 (2.5%) had identified final pathologic findings where axillary staging with SLNB was beneficial. There was no evidence of arm lymphedema in any patient who had undergone CPM and SLNB at a median follow-up of 24 months.

CONCLUSION

Although SLNB is a minimally invasive method of axillary staging, this retrospective study does not support its routine use in patients undergoing CPM.

Efficacy of Prophylactic Mastectomy in Women With Unilateral Breast Cancer: A Cancer Research Network Project

Purpose

We investigated the efficacy of contralateral prophylactic mastectomy (CPM) in reducing contralateral breast cancer incidence and breast cancer mortality among women who have already been diagnosed with breast cancer.

Methods

This retrospective cohort study comprised approximately 50,000 women who were diagnosed with unilateral breast cancer during 1979 to 1999. Using computerized data confirmed by chart review, we identified 1,072 women (1.9%) who had CPM. We obtained covariate information for these women and for a sample of 317 women who did not undergo CPM.

Results

The median time from initial breast cancer diagnosis to the end of follow-up was 5.7 years. Contralateral breast cancer developed in 0.5% of women with CPM, metastatic disease developed in 10.5%, and subsequent breast cancer developed in 12.4%; 8.1% died from breast cancer. Contralateral breast cancer developed in 2.7% of women without CPM, and 11.7% died of breast cancer. After adjustment for initial breast cancer characteristics, treatment, and breast cancer risk factors, the hazard ratio (HR) for the occurrence of contralateral breast cancer after CPM was 0.03 (95% CI, 0.006 to 0.13). After adjustment for breast cancer characteristics and treatment, the HRs for the relationship of CPM with death from breast cancer, with death from other causes, and with all-cause mortality were 0.57 (95% CI, 0.45 to 0.72), 0.78 (95% CI, 0.57 to 1.06), and 0.60 (95% CI, 0.50 to 0.72), respectively.

Conclusion

CPM seems to protect against the development of contralateral breast cancer, and although women who underwent CPM had relatively low all-cause mortality, CPM also was associated with decreased breast cancer mortality.

Aromatase Inhibitors for the Treatment and Prevention of Breast Cancer

In a review of current information on aromatase inhibitors (AIs) and their use in breast cancer treatment and prevention, published reports were obtained through a Medline search. Tamoxifen, a selective estrogen receptor modulator, is approved for use in metastatic breast cancer (MBC), the adjuvant treatment of breast cancer, and the prevention of breast cancer in women at high risk. The 50% reduction in breast cancer incidence seen with tamoxifen is significant for women at increased risk but is accompanied by notable toxicities such as thrombotic events and endometrial cancer. Therefore, the development of other effective agents with less toxicity would be a major advance in breast cancer prevention. Aromatase inhibitors, recently approved for the treatment of MBC and in the adjuvant setting, are proving to be slightly more effective than tamoxifen therapy. These drugs, approved for use in only postmenopausal women, inhibit the enzyme aromatase and thereby lower circulating functional estrogen. To date, the most concerning side effect of these agents is an increase in fracture rate. Compared with tamoxifen, thrombotic events and endometrial cancer rates are much lower. Ongoing data from the Arimidex, Tamoxifen, Alone or in Combination trial continue to favor anastrozole over tamoxifen in the reduction of primary contralateral breast cancers. This information has prompted breast cancer chemoprevention trials with AIs. Although tamoxifen is the gold standard for prevention therapy, results of ongoing studies may indicate a role for AIs in the prevention of breast cancer.

Risk factors for breast cancer: a systematic review of studies with female samples among the general population in Brazil

A systematic review of studies was conducted to determine the characteristics of epidemiological research on risk factors for breast cancer in female samples from the general population in Brazil. Of the 23 articles identified, only 14 were selected for review. Most of the studies were from Southeast Brazil. Three were cross-sectional, conducted in specific populations, and 11 used case-control designs. The sample sizes varied from 40 to 164,269 women. Twenty-nine risk factors were researched, and among these, 11 were investigated in four or more studies. Nulliparity was the most frequent factor, found in 12 of the studies. Prevalence of the factors varied widely among the samples, and since the samples were heterogeneous and the studies presented several methodological limitations, a summary mean was not calculated.

Surgical risk reduction: prophylactic salpingo-oophorectomy and prophylactic mastectomy

Investigators have used retrospective and prospective study designs to provide much needed data on the extent of risk reduction after prophylactic oophorectomy and mastectomy in women at increased risk for breast and ovarian cancer. In this publication we identify those women who may wish to consider prophylactic surgery, review data demonstrating the efficacy of prophylactic surgery, and discuss potential surgical complications. We also present data about the frequency of use and psychosocial impact of prophylactic surgery in this typically young group of women. Finally, we provide general treatment guidelines for the practicing clinician.

Determining the Main Risk Factors and High-risk Groups of Breast Cancer Using a Predictive Model for Breast Cancer Risk Assessment in South Korea

This study was aimed at developing a predictive model for assessing the breast cancer risk of Korean women under the assumption of differences in the risk factors between Westerners and Koreans. The cohort comprised 384 breast cancer patients and 2 control groups: one comprising 166 hospitalized patients and the other comprising 104 nurses and teachers. Two initial models were produced by comparing cases and the 2 control groups, and the final equations were established by selecting highly significant variables of the initial models to test the accuracy of the models in terms of disease probability and predictability. Both the initial models and the final disease-probability models were confirmed to exhibit high degrees of accuracy and predictability. Major risk factors determined by comparing the patients with hospitalized controls were a family history, menstrual regularity, total menstrual duration, age at first full-term pregnancy, and duration of breastfeeding. Major risk factors determined by comparing patients with nurse/teacher controls were age, education level, menstrual regularity, drinking status, and smoking status. The predictive model developed here shows that risk factors for breast cancer differ between Korean and Western subjects in the aspect of breastfeeding behavior. However, identifying the relationship between genetic susceptibility and breast cancer will require further studies with larger samples. In a model with nurse/teacher controls, drinking and higher education were found to be protective variables, whereas smoking was a risk factor. Hence the predictive model in this group could not be generalized to the Korean population; instead, breast cancer incidence needs to be compared among nurses and teachers in a nurse-and-teacher cohort.

Socio-cultural influences on Chinese women's attendance for cervical screening

BACKGROUND

Compared with other countries, Hong Kong has a relatively high rate of cervical cancer. Much of this morbidity should be avoidable with cervical screening, but uptake rates for screening in Hong Kong are low. In programmes to promote cervical screening attendance, it is essential that aspects of the socio-cultural system be taken into account to provide appropriate preventive health strategies.

AIM

This paper outlines an investigation of the cultural and social factors contributing to Chinese women's attendance for cervical screening.

METHOD

A mixed methods design was employed, combining and comparing two data sets. The initial data set was drawn from 10 focus groups involving both screened and unscreened Chinese women (n = 54). The second data set was drawn from a total population of Hong Kong doctors, and involved face-to-face semi-structured interviews (n = 28).

RESULTS

Thematic analysis of the data from women indicated that the social factors of cost, educational base, knowledge of risk, the social value of early detection and cultural issues such as modesty and embarrassment contributed to screening attendance. The doctors perceived a cultural tendency towards fatalism, as well as seeing the gender, interpersonal and interprofessional skills of the practitioner to be important in influencing levels of Chinese women's shyness and discomfort, and hence affecting attendance. The lay and practitioner data sets varied in the perceptions of women's pain, embarrassment and risk factors.

CONCLUSION

Programmes providing services for Chinese women need to ensure that the philosophy of the staff and the approach and materials used are culturally relevant. Recommendations are that nurses equipped with relevant social and cultural knowledge of population groups should have a central role in health promotion and screening services.

Risk estimation for breast cancer development; a clinical perspective

Breast cancer is the commonest cancer among women and the second highest cause of cancer death. It remains a significant health problem and represents a significant worry for many women and their physician. During the last years, intensive research has been focused on accurate risk estimation for breast cancer development. The aim of these efforts is to identify the "high-risk" group of women for breast cancer development. Preventive strategies (including intensive surveillance, chemoprevention, or prophylactic mastectomy) may be applied for the women at high risk for breast cancer development. Given the many management options, it seems reasonable that management of the high-risk woman be tailored to the level of risk she is willing to accept. In estimating the risk for breast cancer development, several factors should be taken into account (including age, reproductive factors, such as age at menarche and age at menopause or pregnancy and age at first live birth, history of benign breast lesions or breast cancer in situ [LCIS/DCIS], prior history of breast cancer, history of familiar or hereditary breast cancer, and environmental and lifestyle factors). Recently, quantitative risk estimation is possible by combining multiple risk factors into a comprehensible risk expression; this is of significant clinical importance, since it will reduce the considerable variation in management among health care providers. The Gail and the Claus model are the most widely used models for quantitative risk estimation. However, the clinician should understand that all models have some limitations that should be recalled as they are applied. It should be emphasized that risk assessment is a serious undertaking and should only be performed by those who have in-depth knowledge about risk factors, family pedigree analysis, comparative statistics, genetics susceptibility testing and the science of probability.

The self-reported likelihood of patient delay in breast cancer: new thoughts for early detection

BACKGROUND

Delayed presentation of self-discovered breast symptoms influences stage of cancer at diagnosis and decreases breast cancer survival.

METHODS

A total of 699 asymptomatic women (black, white, and Latino), recruited in community settings and stratified by age, income, and educational level, were surveyed for their likelihood to delay (J-Delay scale) in the event of a breast symptom discovery. Models of likelihood were tested with logistic regression analyses.

RESULTS

A total of 166 women (23.7%) reported likelihood to delay. Lower income, lower educational level, self identification as Latino or black, experienced prejudice in care delivery, perceived lack of access to health care, fatalism about breast cancer, poor health care utilization habits, self-care behavior, spouse/partner and employer perceived constraints, problem-solving style, and a lack of knowledge of breast cancer's presenting symptoms were associated with likelihood to delay. A combined sample multiple logistic regression model correctly predicted 40.6% of women reporting a likelihood to delay, 94.9% of those not likely to delay, and 82.4% (551 of 669) of cases overall.

CONCLUSIONS

Self-reported likelihood of patient delay is measurable in advance of symptom occurrence, and this measure is consistent with behavioral and knowledge variables previously linked with advanced breast cancer at diagnosis.

Utility and treatment decisions: 15 clinical cases in Japan

The purpose of this study was to investigate the applicability of utility concepts to treatment decision making in different clinical situations. In each of the 15 independent cases studied, subjective utility values were obtained directly from the patients before the treatment decisions were made. The optimal decision based on the utility values was then calculated. The actual treatment decisions were made without any input or influence by this study. The data were obtained at two large public hospitals and two privately owned multi-service hospitals in Kobe, Japan. Active participation by patients in treatment decision making seems particularly useful when two or more treatments are approximately equivalent in terms of outcome. A careful assessment of an individual patient's utilities can help the patient choose a treatment option meeting individual goals. Patient autonomy must be strengthened by giving the patients realistic and unbiased information of the alternatives available and the possible outcomes.

Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer

PURPOSE

To estimate the efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.

PATIENTS AND METHODS

We followed the course of 745 women with a first breast cancer and a family history of breast and/or ovarian cancer who underwent contralateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. Family history information and cancer follow-up information were obtained from the medical record, a study-specific questionnaire, and telephone follow-up. Life-tables for contralateral breast cancers, which consider age at first breast cancer, current age, and type of family history, were used to calculate the number of breast cancers expected in our cohort had they not had a prophylactic mastectomy.

RESULTS

Of the 745 women in our cohort, 388 were premenopausal (age < 50 years) and 357 were post- menopausal. Eight women developed a contralateral breast cancer. Six events were observed among the premenopausal women, compared with 106.2 predicted, resulting in a risk reduction of 94.4% (95% confidence interval [CI], 87.7% to 97.9%). For the 357 postmenopausal women, 50.3 contralateral breast cancers were predicted, whereas only two were observed, representing a 96.0% risk reduction (95% CI, 85.6% to 99.5%).

CONCLUSION

The incidence of contralateral breast cancer seems to be reduced significantly after contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.

Breast cancer after prophylactic bilateral mastectomy in women with a BRCA1 or BRCA2 mutation

BACKGROUND

Women with a BRCA1 or BRCA2 mutation have a high risk of breast cancer and may choose to undergo prophylactic bilateral total mastectomy. We investigated the efficacy of this procedure in such women.

METHODS

We conducted a prospective study of 139 women with a pathogenic BRCA1 or BRCA2 mutation who were enrolled in a breast-cancer surveillance program at the Rotterdam Family Cancer Clinic. At the time of enrollment, none of the women had a history of breast cancer. Seventy-six of these women eventually underwent prophylactic mastectomy, and the other 63 remained under regular surveillance. The effect of mastectomy on the incidence of breast cancer was analyzed by the Cox proportional-hazards method in which mastectomy was modeled as a time-dependent covariate.

RESULTS

No cases of breast cancer were observed after prophylactic mastectomy after a mean (+/-SE) follow-up of 2.9+/-1.4 years, whereas eight breast cancers developed in women under regular surveillance after a mean follow-up of 3.0+/-1.5 years (P=0.003; hazard ratio, 0; 95 percent confidence interval, 0 to 0.36). The actuarial mean five-year incidence of breast cancer among all women in the surveillance group was 17+/-7 percent. On the basis of an exponential model, the yearly incidence of breast cancer in this group was 2.5 percent. The observed number of breast cancers in the surveillance group was consistent with the expected number (ratio of observed to expected cases, 1.2; 95 percent confidence interval, 0.4 to 3.7; P=0.80).

CONCLUSIONS

In women with a BRCA1 or BRCA2 mutation, prophylactic bilateral total mastectomy reduces the incidence of breast cancer at three years of follow-up.

Educational Review: Role of the Surgeon in Hereditary Breast Cancer

Up to 10% of the breast cancers detected in the United States are related to an inherited germline mutation, usually in the BRCA1 or BRCA2 genes, and the majority of these patients will at some point require surgical evaluation and/or treatment. Women who harbor a genetic predisposition for breast cancer face an increased risk for early onset disease, bilateral tumors, and other non-breast malignancies, such as ovarian cancer. These issues raise questions regarding the appropriate surveillance regimen, and the potential efficacy of risk reduction strategies that should be considered. Once a breast cancer diagnosis has been established, the prognosis appears to be similar to stage-controlled sporadic breast cancer, despite an increased prevalence of adverse primary tumor features. However, the role of breast conservation therapy for these patients and the optimal means of addressing the substantially increased risk for contralateral tumors is not yet defined. The reported literature in this area, including a discussion of the value of genetic counseling and genetic testing, is reviewed.

Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer

BACKGROUND

Risk factors for contralateral breast cancer (CBC) may indicate a benefit for contralateral prophylactic mastectomy (CPM) at the time of unilateral mastectomy for breast cancer. The purpose of this study is to evaluate the efficacy of CPM in preventing CBC.

METHODS

sixty-four patients undergoing CPM and a control group of 182 patients not undergoing CPM and matched for age, stage, surgery, chemotherapy, and hormonal therapy were retrospectively compared for CBC rate, disease-free survival, and overall survival.

RESULTS

Thirty-six CBCs occurred in the control group. In the CPM group, 3 CBCs were found at the time of prophylactic mastectomy, but none occurred subsequently (P = 0.005). Disease-free survival at 15 years in the CPM group was 55% (95% confidence interval [CI] 38% to 69%) versus 28% (95% CI 19% to 36%) in the control group (P = 0.01). Overall survival at 15 years was 64% (95% CI 45% to 78%) CPM versus 48% (95% CI 39% to 58%) in controls (P = 0.26).

CONCLUSION

CPM prevented CBC and significantly prolonged disease-free survival. Future studies will need to address risk assessment and contralateral breast cancer prevention in patients treated for early breast cancer.

The breast surgeon's role in BRCA1 and BRCA2 testing

Five percent to 10% of all women who develop breast cancer carry a hereditary mutation in the genes BRCA1 or BRCA2. Genetic testing is now clinically available, and the results of such testing can dramatically alter a patient's risks for an ipsilateral or contralateral primary breast cancer and ovarian cancer. Therefore, genetic testing will become integral in tailoring surveillance, chemoprevention, and surgical management plans for patients at risk for hereditary cancer syndromes. Such results will also impact the cancer risks for the patient's nuclear and extended family members. Surgeons will play a pivotal role in eliciting personal and family histories from patients, determining which of those histories is suggestive of a germline mutation, facilitating referrals for genetic counseling and testing, and incorporating the results of genetic testing into the patient's short- and long-term management plans.

Breast cancer: risk factors, screening, and prevention

OBJECTIVES

To provide a review of the major and minor risk factors for the development of breast cancer and the options for prevention and treatment in women at high risk for breast cancer.

DATA SOURCES

Clinical and research articles and textbooks.

CONCLUSIONS

Breast cancer is the leading cancer found in women in the United States. For high-risk women, understanding their risk, appropriate screening recommendations, and possible prevention strategies is paramount.

IMPLICATIONS FOR NURSING PRACTICE

Through education and psychosocial support, the nurse can assist with decision-making regarding risk reduction and current prevention and treatment options.

Culture as an influence on breast cancer screening and early detection

OBJECTIVES

To explore how culture may play a part in breast cancer screening, early detection, and efforts to decrease breast mortality.

DATA SOURCES

Journal articles published in the past 20 years on cultural aspects of cancer prevention and control.

CONCLUSIONS

Research seems directed more at discovering cultural differences than at identifying similarities on how culture influences breast cancer screening and early detection. The influences of poverty and lack of educational opportunities account for much of what is termed cultural difference.

IMPLICATIONS FOR NURSING PRACTICE

Improving practice through an informed understanding of culture calls for considerable self-education and a fundamental refinement of care delivery.

Perceived risk and help-seeking behavior for breast cancer. A Chinese-American perspective

Delay in the diagnosis and treatment of breast cancer diminishes a woman's chance of survival. How do women decide whether and when to seek an evaluation of breast symptoms that may signal breast cancer? Prior studies of African-American, white, and Latino women have described a number of critical factors associated with making the judgment to delay, but at this writing, there have been no studies factors influencing Chinese-American women. By means of focus group methods in English, Mandarin, and Cantonese, a sample of 45, predominantly first-generation Chinese-American women explained their understanding of breast cancer risk and their likelihood of delaying versus seeking evaluation of self-discovered breast symptoms. There was much congruence with the ideas of other American women despite the differing cultural heritage. Unique to these Chinese Americans was a sense of invulnerability to breast cancer, a linking of cancer to tragic luck, and the predominant likelihood of delay. To preserve modesty and to conserve wealth and time, many study participants favored using Chinese medicine and delaying Western therapies. This study suggests ways by which health care providers must approach guidelines for breast cancer early detection in this population.

Prophylactic mastectomy or screening in women suspected to have the BRCA1/2 mutation: a prospective pilot study of women's treatment choices and medical and decision-analytic recommendations

BACKGROUND

Women suspected to have the BRCA1/2 mutation may choose between two management options: breast cancer screening and prophylactic mastectomy (PM).

OBJECTIVES

To compare women's treatment choices with medical and decision-analytic recommendations and to explore variables related to the women's choices.

METHODS

After provision of information, individual time-tradeoff values for the health outcome "living after PM" were assessed and incorporated into a decision-analytic model, which compared the management options PM and screening with respect to their effects on quality-adjusted life expectancy.

RESULTS

Of the 54 women suspected to have the mutation, 51 completed the shared-decision-making procedure. Quality-adjusted life expectancy after PM management was longer for 67% of proven carriers and for 58% of women awaiting the DNA-test result. Twelve proven carriers made definitive treatment choices: eight (67%) chose PM and four (33%) chose screening. All carriers' treatment choices agreed with the normative decision-analytic recommendations. Four (33%) disagreed with the medical recommendations. Of the 36 women awaiting DNA-test results, 32 made hypothetical treatment choices. The agreement between these hypothetical treatment choices and the decision-analytic recommendations was good (78%). Combining data from all 48 women, being married (OR = 14.00, p = 0.006), having children (OR = 4.71, p = 0.02), low desire to participate (OR = 0.14, p = 0.004), high decisional stress (OR = 5.22, p = 0.01), a lower estimate of the "probability of cure for screen-detected breast cancer" (OR = 0.13, p = 0.004), and higher time-tradeoff values for PM (OR = 182, p < 0.0001) made a choice for PM more likely.

CONCLUSIONS

The complete agreement between the decision-analytic recommendations and the carriers' choices suggests that women act in accordance with normative decision theory. The disagreement between the carriers' choices and the medical recommendations suggests that women's choices and physicians' recommendations were guided by different arguments. The strong association between time-tradeoff value and treatment choice suggests that the time-tradeoff is a valid method to assess preferences.

Prophylactic surgery for women at high risk for breast cancer

Women at high risk for the development of breast cancer have several options open to them including increased cancer surveillance, prophylactic mastectomy and/or oophorectomy, and chemoprevention. We consider high-risk women to be those with known BRCA mutations or a strong family history characterized by multiple relatives with breast cancer, early age at diagnosis, and in some families, ovarian cancer. We present existing data regarding prophylactic surgery for these women. Essentially, a woman at high risk for breast cancer may choose to undergo bilateral prophylactic mastectomy, with or without reconstruction. For patients who have a known breast cancer, contralateral mastectomy is also an option. Finally, for women in families with a strong incidence of ovarian cancer, prophylactic oophorectomy can be considered.

Prophylactic mastectomy; evolving perspectives

It is not at all uncommon for surgeons dealing with breast disease to be confronted with the issue of prophylactic mastectomy. Recent advances in understanding the genetic basis of susceptibility to breast cancer and a better identification of the histological factors affecting a woman's lifetime risk of developing breast cancer have contributed to placing prophylactic mastectomy in a proper clinical perspective. Existing data suggest that prophylactic total mastectomy significantly reduces, but does not totally eliminate, the risk of subsequent development of cancer. However, the benefit of prophylactic mastectomy over alternative strategies (surveillance and chemoprevention) remains to be proven. Currently, prophylactic mastectomy may be considered in a few, carefully selected patients. The decision to perform a prophylactic mastectomy should be a multidisciplinary one. Detailed patient' counselling is very important; the patient should understand the limitations of prophylactic mastectomy and the need for postoperative follow-up. Furthermore, she should be well informed about the alternative strategies.

Evaluation and treatment of BRCA-positive patients

The recent discovery of the breast cancer-associated genes BRCA1 and BRCA2 has now made it possible to identify individuals who are at a very high risk for the future development of breast cancer. To some extent, however, society has fallen victim to its molecular genetic technology. The significance of these discoveries to the detection, treatment, and prevention of breast cancer cannot be overstated. Nevertheless, the appropriate administration and interpretation of BRCA genetic testing and the treatment of BRCA-positive patients remain controversial issues. Complexities of BRCA testing require that such genetic screening be restricted to selected high-risk patients and that test results be interpreted by a knowledgeable molecular geneticist. Although no medical prophylaxis has been demonstrated to be of benefit in BRCA-positive patients, recent evidence suggests that a prophylactic mastectomy, with or without reconstruction, is a reasonable treatment option that substantially reduces cancer risk.

Clinical options for women at high risk for breast cancer

Women at hereditary risk of breast cancer face a difficult clinical decision. Each of the options available to them has unique advantages and disadvantages that are summarized in Table 9. Many components enter a high-risk woman's decision: her objective risk of breast cancer; clinical features, such as the consistency of breast tissue and resultant ease of examination; breast density on mammography; personal characteristics, including her experience with cancer within her family; her role and [table: see text] responsibilities within her own nuclear family; her values and goals; her experiences with the medical system; and her subjective assessment of risk. It is generally believed that women significantly overestimate their risk of breast cancer. Thus, it is vital that a woman at risk have access to a genetic counselor who can provide accurate assessment of her risk. Women should be encouraged to take time to understand their risk level and the advantages and disadvantages of the options before them.

Estrogen replacement therapy and breast cancer: analysis of age of onset and tumor characteristics

BACKGROUND

The use of exogenous estrogen has been scrutinized as a risk factor for breast cancer formation. This prospective study addresses the relationship between the use of estrogen replacement therapy and the age of onset of breast cancer. In addition, an analysis of differences in pathological features of breast cancer between estrogen users and non-estrogen-users was evaluated.

METHODS

A total of 425 women (age, > or = 50 years) were evaluated during a 4-year period (1994-1997). Data, including the age at diagnosis, method of detection, family history, use of estrogen therapy, and tumor ploidy, S-phase fraction, histological category, estrogen receptor positivity, and grade, were prospectively collected. Data from a control group of 657 women without a diagnosis of breast cancer were obtained from the Evanston Northwestern division of the Women's Health Initiative. Significant associations between the use of estrogen and pathological parameters were determined using the chi2 test and t-test (P < .05).

RESULTS

At the time of breast cancer diagnosis, 140 patients were currently receiving estrogen and 202 patients had no history of estrogen use. Eighty-three patients were excluded from analysis (76 patients had a history of previous but not current use of estrogen therapy, four women used only progesterone, and three patients provided incomplete information). There was no difference between patients with breast cancer using estrogen at the time of diagnosis and those with no history of estrogen use with respect to tumor size, age of menopause, family history, mammographic sensitivity, axillary lymph node status, and histological features. Women using estrogen at the time of diagnosis were younger at the time of breast cancer diagnosis, by an average of 5.1 years (61.3 years vs. 66.4 years, P < .001). Women without a history of breast cancer who were receiving estrogen therapy were an average of 2.4 years younger (63.3 years vs. 65.7 years, P < .001) than women without a history of breast cancer who were not receiving estrogen therapy. Patients with breast cancer receiving estrogen also tended to have more grade II tumors (45.9% vs. 36.5%, P = .045) and fewer grade III tumors (25.6% vs. 37.0%, P = .015), compared with women not receiving estrogen therapy at the time of their diagnoses. Estrogen receptor positivity was noted to be more frequent for estrogen users presenting with lobular carcinoma (85% vs. 76%, P = .042) and less frequent for estrogen users presenting with ductal carcinoma (72% vs. 85%, P = .003).

CONCLUSIONS

A significantly earlier age of diagnosis for women receiving estrogen therapy suggests that exogenous estrogen may accelerate the pathogenesis of postmenopausal breast cancer. Estrogen therapy may also play a role in altering the grade and estrogen receptor positivity for certain histological types of breast cancer.

Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer

BACKGROUND

Options for women at high risk for breast cancer include surveillance, chemoprevention, and prophylactic mastectomy. The data on the outcomes for surveillance and prophylactic mastectomy are incomplete.

METHODS

We conducted a retrospective study of all women with a family history of breast cancer who underwent bilateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. The women were divided into two groups - high risk and moderate risk - on the basis of family history. A control study of the sisters of the high-risk probands and the Gail model were used to predict the number of breast cancers expected in these two groups in the absence of prophylactic mastectomy.

RESULTS

We identified 639 women with a family history of breast cancer who had undergone bilateral prophylactic mastectomy: 214 at high risk and 425 at moderate risk. The median length of follow-up was 14 years. The median age at prophylactic mastectomy was 42 years. According to the Gall model, 37.4 breast cancers were expected in the moderate-risk group; 4 breast cancers occurred (reduction in risk, 89.5 percent; P<0.001). We compared the numbers of breast cancers among the 214 high-risk probands with the numbers among their 403 sisters who had not undergone prophylactic mastectomy. Of these sisters, 38.7 percent (156) had been given a diagnosis of breast cancer (115 cases were diagnosed before the respective proband's prophylactic mastectomy, 38 were diagnosed afterward, and the time of the diagnosis was unknown in 3 cases). By contrast, breast cancer was diagnosed in 1.4 percent (3 of 214) of the probands. Thus, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90 percent.

CONCLUSIONS

In women with a high risk of breast cancer on the basis of family history, prophylactic mastectomy can significantly reduce the incidence of breast cancer.

Breast carcinoma in residual breast tissue after prophylactic bilateral subcutaneous mastectomy

We report a case of breast carcinoma 6 years after a prophylactic subcutaneous mastectomy. The incidence of breast carcinoma after prophylactic mastectomy is probably less than 2%. If removal of breast tissue is performed to prevent breast cancer, we advocate a complete simple bilateral mastectomy, including nipple-areola complex, axillary tail and pectoral fascia.