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Apostolova C, Ferroum A, Alhassan B, Prakash I, Basik M, Boileau JF, Martel K, Meterissian S, Villareal Corpuz V, Wong N, Foulkes WD, Wong SM. Timing of genetic testing in BRCA1/2 and PALB2-Associated breast cancer: Preoperative result disclosure increases uptake of risk-reducing mastectomy and reduces unnecessary exposure to radiotherapy. Eur J Surg Oncol 2024; 50:108324. [PMID: 38636249 DOI: 10.1016/j.ejso.2024.108324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/25/2024] [Accepted: 04/06/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION The impact of timing of genetic testing on uptake of risk reducing mastectomy (RRM) in affected female BRCA1/2 or PALB2 carriers remains an area of evolving interest, particularly with the introduction of mainstream genetic testing initiatives. METHODS Women with stage I-III breast cancer and a confirmed germline pathogenic variant in BRCA1/2 or PALB2 between 2000 and 2023 were identified from an institutional genetics database. Uptake of RRM was evaluated according to disclosure of genetic testing results before or after index surgery for a first diagnosis of breast cancer. RESULTS The cohort included 287 female BRCA1/2 or PALB2 carriers with a median age of 44 years (IQR, 36-52). Overall, 155 (54 %) carriers received genetic testing results before and 132 (46 %) after index breast surgery. Receipt of genetic testing results before surgery was associated with a higher rate of index bilateral mastectomy (58.7 % vs. 7.6 %, p < 0.001) and a commensurate decrease in adjuvant radiation (41.9 % vs. 74.2 %, p < 0.001). At a median follow up of 4.4 years after genetic testing, 219 (76.3 %) affected carriers had undergone bilateral RRM, including 83.9 % with preoperative knowledge and 67.4 % of patients with postoperative knowledge of their germline pathogenic variant (log rank, p < 0.001). On multivariate regression, disclosure of genetic testing results before index breast surgery was independently associated with long-term uptake of bilateral mastectomy (HR 1.69, 95 % CI 1.21-2.38). CONCLUSION Genetic testing results delivered prior to index breast surgery increase uptake of bilateral RRM in affected BRCA1/2 and PALB2 carriers. Efforts to mainstream genetic testing would help optimize surgical decision-making.
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Affiliation(s)
- Carla Apostolova
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Amina Ferroum
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Basmah Alhassan
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Ipshita Prakash
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal, QC, Canada; Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Mark Basik
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | | | - Karyne Martel
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
| | - Sarkis Meterissian
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | | | - Nora Wong
- Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal, QC, Canada; Department of Human Genetics, McGill University Medical School, Montreal, QC, Canada
| | - William D Foulkes
- Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal, QC, Canada; Department of Oncology, McGill University Medical School, Montreal, QC, Canada; Department of Human Genetics, McGill University Medical School, Montreal, QC, Canada
| | - Stephanie M Wong
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada; Stroll Cancer Prevention Centre, Jewish General Hospital, Montreal, QC, Canada; Department of Oncology, McGill University Medical School, Montreal, QC, Canada.
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Taris N, Luporsi E, Osada M, Thiblet M, Mathelin C. [News in breast oncology genetics for female and male population]. Gynecol Obstet Fertil Senol 2024; 52:149-157. [PMID: 38190969 DOI: 10.1016/j.gofs.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 12/30/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVES Breast oncology genetics emerged almost 30 years ago with the discovery of the BRCA1 and BRCA2 genes. The evolution of analytical practices has progressively allowed access to tests whose results now have a considerable impact on the management of both female and male breast cancers. The Sénologie commission of the Collège national des gynécologues et obstétriciens français (CNGOF) asked five specialists in breast surgery, oncology and oncological genetics to draw up a summary of the oncogenetic testing criteria used and the clinical implications for the female and male population of the test results, with or without an identified causal variant. In the case of proven genetic risk, surveillance, risk-reduction strategies, and the specificities of surgical and medical management (with PARP inhibitors in particular) were updated. METHODS This summary was based on national and international guidelines on the monitoring and therapeutic management of genetic risk, and a recent review of the literature covering the last five years. RESULTS Despite successive technical developments, the probability of identifying a causal variant in a situation suggestive of a predisposition to breast and ovarian cancer remains around 10% in France. The risk of breast cancer in women with a causal variant of the BRCA1, BRCA2, PALB2, TP53, CDH1 and PTEN genes is estimated at between 35% and 85% at age 70. The presence of a causal variant in one of these genes is the subject of different recommendations for men and women, concerning both surveillance, the age of onset and imaging modalities of which vary according to the genes involved, and risk-reduction surgery, which is possible for women as soon as their risk level exceeds 30% and remains exceptionally indicated for men. In the case of breast cancer, PARP inhibitors are a promising new class of treatment for BRCA germline mutations. CONCLUSION A discipline resolutely focused on understanding molecular mechanisms, screening and preventive medicine/surgery, oncology genetics is currently also involved in new medical/surgical approaches, the long-term benefits/risks of which will need to be monitored.
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Affiliation(s)
- Nicolas Taris
- Unité de génétique oncologique, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France.
| | - Elisabeth Luporsi
- Service de génétique, hôpital Femme-Mère-Enfant, CHR de Metz-Thionville, Site de Mercy, 1, allée du Château, 57085 Metz cedex, France.
| | - Marine Osada
- Service de chirurgie, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; CHRU, avenue Molière, 67200 Strasbourg, France.
| | - Marie Thiblet
- Service de chirurgie, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; CHRU, avenue Molière, 67200 Strasbourg, France.
| | - Carole Mathelin
- Service de chirurgie, ICANS, avenue Albert-Calmette, 67200 Strasbourg, France; CHRU, avenue Molière, 67200 Strasbourg, France.
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Apostolova C, Ferroum A, Alhassan B, Prakash I, Viezel-Mathieu A, Basik M, Boileau JF, Meterissian S, Wong N, Foulkes WD, Wong SM. Surgical Decision Making in Genetically High-Risk Women: Quantifying Postoperative Complications and Long-Term Risks of Supplemental Surgery After Risk-Reducing Mastectomy. Ann Surg Oncol 2024; 31:356-364. [PMID: 37838650 DOI: 10.1245/s10434-023-14418-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/25/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Risk-reducing mastectomy (RRM) helps prevent breast cancer in high-risk women but also carries a risk of unanticipated supplemental surgeries. We sought to determine the likelihood of supplemental surgeries following RRM. METHODS We performed a retrospective cohort study of female patients with a confirmed germline pathogenic variant (GPV) in a breast cancer susceptibility gene (BRCA1/2, PALB2 and others) who underwent bilateral or contralateral RRM at our institution between 2006 and 2022. Supplemental surgeries were defined as any operation requiring general or local anesthesia performed outside of the initially planned procedure(s). The Kaplan-Meier method was used to estimate the 5-years cumulative incidence of supplemental surgery. RESULTS Of 560 GPV carriers, RRMs were performed in 258 (46.1%) women. The median age of the cohort was 44 years (interquartile range 37-52 years), with 33 (12.8%) patients undergoing RRM without reconstruction and 225 (87.2%) undergoing RRM with reconstruction. Following surgery, 34 patients (13.2%) developed early (< 30 days) postoperative complications, including infection, hematoma, seroma, loss of the nipple areola complex, flap necrosis, implant exposure and/or prosthesis removal. At a median follow-up of 3.8 years, 94 (36.4%) GPV carriers underwent at least one reoperation. Participants who experienced an early postoperative complication had the highest rate of reoperation (85.3% vs. 29.0%; p < 0.001) and a significantly higher likelihood of multiple additional surgical interventions (41.2% vs. 10.7%; p < 0.001). The 5-years rate of supplemental surgery was 39.2% [95% confidence interval (CI) 32.7-46.5] in the overall cohort and 31.5% (95% CI 24.9-39.3) in patients without an early postoperative complication. CONCLUSIONS Unanticipated supplemental surgeries occur in 40% of GPV carriers following RRM and in nearly one-third of patients without early postoperative complications.
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Affiliation(s)
- Carla Apostolova
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Amina Ferroum
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Basmah Alhassan
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Ipshita Prakash
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Alex Viezel-Mathieu
- Department of Plastic and Reconstructive Surgery, McGill University Medical School, Montreal, QC, Canada
| | - Mark Basik
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | | | - Sarkis Meterissian
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Nora Wong
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
- Department of Human Genetics, McGill University Medical School, Montreal, QC, Canada
| | - William D Foulkes
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
- Department of Human Genetics, McGill University Medical School, Montreal, QC, Canada
| | - Stephanie M Wong
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada.
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada.
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada.
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Mohrmann S, Kolberg L, Jäger B, Hoffmann J, Nestle-Krämling C, Zwiefel K, Friebe V, Sawicki LM, Bruckmann NM, Jannusch K, Morawitz J, Antoch G, Fehm TN, Kirchner J, Dietzel F. Impact of surgical variables on residual glandular tissue in risk-reducing mastectomies: Results of a retrospective monocentric study from a center of the German consortium for hereditary breast and ovarian cancer. Eur J Surg Oncol 2023; 49:107031. [PMID: 37683424 DOI: 10.1016/j.ejso.2023.107031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/06/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE Residual glandular tissue (RGT) after risk reducing mastectomy (RRME) is associated with a risk of developing breast cancer for women with a familial predisposition. We aim to examine various surgery-related variables to make risk more easily assessable and to aid in decision-making. MATERIALS AND METHODS Pre- and postoperative breast MRI scans from 2006 to 2021 of patients with proven pathogenic mutation were included. The postoperative remaining skin flap was recorded using distance measurements at 8 equally distributed clockwise points and retromamillary. Each breast was volumetrized, as well as existing RGT. Patient-related covariates were further recorded and their influence on RGT was investigated uni- and multivariately. RESULTS 81 patients (49 with BRCA1, 24 with BRCA2, 9 with other mutations), who were on average 39 years old, had 117 breasts analyzed. The mean follow-up was 71 months. In multivariate analysis, the independent variable skin flap thickness had a positive effect (p ≤ 0.01), while surgeon experience negatively affected RGT (p ≤ 0.05). The incision type was found to impact RGT as well, with nipple-sparing mastectomy (NSM) with inframammary fold incision leading to more RGT (p ≤ 0.01 - p ≤ 0.05), and skin-sparing mastectomy (SSM) with an inverted T incision leading to less (p ≤ 0.01). CONCLUSION Different surgical variables have an impact on postoperative RGT, which is an important tool to quantify the risk of developing breast cancer after RRME. In order to effectively consider these variables in future preoperative/intraoperative management, they must be carefully taken into account.
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Affiliation(s)
- Svjetlana Mohrmann
- Department of Obstetrics and Gynecology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Leoni Kolberg
- Department of Obstetrics and Gynecology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany; Department of Obstetrics and Gynecology, Agaplesion Bethesda Krankenhaus Wuppertal, 42109, Wuppertal, Germany.
| | - Bernadette Jäger
- Department of Obstetrics and Gynecology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Jürgen Hoffmann
- Department of Obstetrics and Gynecology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | | | - Karin Zwiefel
- Breast Center, Kliniken der Stadt Köln, 51067, Köln, Germany.
| | - Verena Friebe
- Department of Obstetrics and Gynecology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Lino M Sawicki
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Nils Martin Bruckmann
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Kai Jannusch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Janna Morawitz
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Tanja Natascha Fehm
- Department of Obstetrics and Gynecology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Julian Kirchner
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
| | - Frederic Dietzel
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, 40225, Düsseldorf, Germany.
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Dick J, Tüchler A, Brédart A, Vitinius F, Wassermann K, Rhiem K, Schmutzler RK. Psychological factors and the uptake of preventative measures in BRCA1/2 pathogenic variant carriers: results of a prospective cohort study. Hered Cancer Clin Pract 2022; 20:38. [PMID: 36536421 DOI: 10.1186/s13053-022-00244-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Women carrying BRCA1/2 pathogenic variants are exposed to elevated risks of developing breast cancer (BC) and are faced by a complex decision-making process on preventative measures, i.e., risk-reducing mastectomy (RRM), and intensified breast surveillance (IBS). In this prospective cohort study we investigated the effect of anxiety, personality factors and coping styles on the decision-making process on risk management options in women with pathogenic variants in BRCA1/2. METHODS Breast cancer unaffected and affected women with a pathogenic variant in the BRCA1 or BRCA2 gene were psychologically evaluated immediately before (T0), 6 to 8 weeks (T1) and 6 to 8 months (T2) after the disclosure of their genetic test results. Uptake of RRM and IBS was assessed at T2. Psychological data were gathered using questionnaires on risk perception, personality factors, coping styles, decisional conflict, depression and anxiety, including the Hospital Anxiety and Depression Scale (HADS). We performed tests on statistical significance and fitted a logistic regression based on significance level. RESULTS A total of 98 women were included in the analysis. Baseline anxiety levels in women opting for RRM were high but decreased over time, while they increased in women opting for intensified breast surveillance (IBS). Elevated levels of anxiety after genetic test result disclosure (T1) were associated with the decision to undergo RRM (p < 0.01; OR = 1.2, 95% CI = 1.05-1.42), while personal BC history and personality factors seemed to be less relevant. CONCLUSIONS Considering psychosocial factors influencing the decision-making process of women with pathogenic variants in BRCA1/2 may help improving their genetic and psychological counselling. When opting for IBS they may profit from additional medical and psychological counselling. TRIAL REGISTRATION Retrospectively registered at the German Clinical Trials Register under DRKS00027566 on January 13, 2022.
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Dettwyler SA, Thull DL, McAuliffe PF, Steiman JG, Johnson RR, Diego EJ, Mai PL. Timely cancer genetic counseling and testing for young women with breast cancer: impact on surgical decision-making for contralateral risk-reducing mastectomy. Breast Cancer Res Treat 2022; 194:393-401. [PMID: 35596825 DOI: 10.1007/s10549-022-06619-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/25/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE Genetic testing (GT) can identify individuals with pathogenic/likely pathogenic variants (PV/LPVs) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic. METHODS Clinical data were reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤ 45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated. RESULTS Of the 194 patients, 30 (15.5%) had a PV/LPV in a BC predisposition gene (ATM, BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV/LPV carriers and 42/164 (25.6%) non-carriers. A positive test result (p < 0.01) and significant family history were associated with CRRM (p = 0.02). For the 164 with uninformative results, multivariate analysis showed that CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.10), or BC stage (p = 0.11). CONCLUSION In this cohort of young women with BC, the identification of a PV/LPV in a BC predisposition gene and a significant family history were associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.
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Affiliation(s)
- Shenin A Dettwyler
- UPMC Magee-Womens Hospital (Cancer Genetics Program), Pittsburgh, PA, USA. .,Currently at NYU Langone Health (The Pancreatic Cancer Center), New York, NY, USA.
| | - Darcy L Thull
- UPMC Magee-Womens Hospital (Cancer Genetics Program), Pittsburgh, PA, USA
| | | | - Jennifer G Steiman
- UPMC Magee-Womens Hospital (Magee-Womens Surgical Associates), Pittsburgh, PA, USA
| | - Ronald R Johnson
- UPMC Magee-Womens Hospital (Magee-Womens Surgical Associates), Pittsburgh, PA, USA
| | - Emilia J Diego
- UPMC Magee-Womens Hospital (Magee-Womens Surgical Associates), Pittsburgh, PA, USA
| | - Phuong L Mai
- University of Pittsburgh School of Medicine (Center for Clinical Genetics and Genomics), Pittsburgh, PA, USA
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Pitiyarachchi O, Phillips KA, Friedlander M. Pregnancy induced hyperplasia of residual breast tissue following risk reducing contralateral mastectomy - simply interesting or a clinically important observation. Cancer Treat Res Commun 2022; 30:100504. [PMID: 34990902 DOI: 10.1016/j.ctarc.2021.100504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
After a diagnosis of breast cancer women with increased genetic risk often have a risk reducing contralateral mastectomy, and may opt for a nipple or skin sparing mastectomy with immediate reconstruction. A variable amount of residual breast tissue remains which may substantially increase in volume during pregnancy. Whether this increases later risk of breast cancer is unknown. We describe the clinical details of 3 patients with a history of unilateral breast cancer, including 2 with a BRCA mutation, who developed hyperplasia of residual breast tissue in the 3rd trimester of a later pregnancy. They all had a delayed contralateral risk reducing skin sparing mastectomy and immediate reconstruction. Pregnancy occurred some years later. We summarise their management, review the literature and raise questions for discussion. All developed prominent hyperplasia of breast tissue in the 3rd trimester that was clinically obvious asymmetrical breast swelling in the reconstructed contralateral breast. MRI demonstrated substantial breast tissue. The risk of breast cancer, particularly in those at high genetic risk developing in the residual breast tissue is unknown but in view of the volume, breast tissue was excised postpartum. This phenomenon of pregnancy induced hyperplasia of breast tissue after risk reducing mastectomy is not well described .There is residual breast tissue following a risk reducing subcutaneous mastectomy. The risk factors include age and skin flap thickness. MRI can demonstrate the residual breast tissue. Pregnancy induced hyperplasia of residual breast tissue may occur after risk reducing mastectomy with a hypothetical increased risk of subsequent breast cancer.
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Affiliation(s)
- Omali Pitiyarachchi
- Department of Medical Oncology, Prince of Wales Hospital, Barker St, Randwick NSW 2031, Australia; Prince of Wales Clinical School, UNSW Medicine, Sydney, New South Wales, Australia
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; The Sir Peter MacCallum Department of Oncology, the University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Friedlander
- Department of Medical Oncology, Prince of Wales Hospital, Barker St, Randwick NSW 2031, Australia; Prince of Wales Clinical School, UNSW Medicine, Sydney, New South Wales, Australia.
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Arslan B, Tazeoğlu D, Dağ A, Berkeşoğlu M, Özdemir AA. Is there an increasing trend of risk-reducing prophylactic mastectomy procedure in preventing breast cancer among women? Turk J Surg 2021; 37:347-354. [PMID: 35677477 PMCID: PMC9130946 DOI: 10.47717/turkjsurg.2021.4963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/12/2021] [Indexed: 11/23/2022]
Abstract
Objectives Prophylactic contralateral/bilateral mastectomy (PCM/PBM), as a risk-reducing mastectomy procedure, has a few evidence-based indica- tions; however, there is an increasing trend in the total number of operations globally. Worldwide famous actress Angelina Jolie was detected to have BRCA-1 mutation and underwent a prophylactic bilateral mastectomy in 2013. The procedure was perceived as 'lifesaving' worldwide, which eventually led to a significant increase in BRCA gene mutation analysis and PCM/PBM. In this study, it was aimed to evaluate our risk-reducing PCM/PBM results. Material and Methods Twenty-seven patients underwent risk-reducing PCM/PBM between 2010-2018, but only 22 patients were included into the study. A retrospective analysis was carried out on demographics, family history, preoperative diagnoses, pathological findings, mastectomy details, reconstructive procedures, neoadjuvant chemotherapy, BRCA analysis, educational status, and mastectomy indications. Results Surgical indications or major reasons for surgery were as follows: BRCA-1 mutation (n= 5), BRCA-2 mutation (n= 3), malignant-like areas in magnetic resonance imaging (n= 2), lobular carcinoma in situ (n= 3) and intense anxiety (n= 9). Eighteen patients (82%) underwent an additional re- constructive procedure via implantation or autologous tissue and four patients (18%) underwent mastectomy only. PCM/PBM by years was as: 2010 (n= 1), 2011 (n= 0), 2012 (n= 1), 2013 (n= 2), 2014 (n= 1), 2015 (n= 2), 2016 (n= 3), 2017 (n= 4), 2018 (n= 8), which represents the recently increasing trend. Conclusion Risk-reducing PCM/PBM was performed in 59.1% of the patients (n= 13) for a significant medical reason, whereas for distress about a relapse or a new disease on the contralateral breast on the remaining 40.9% of the patients (n= 9). Evidence in the literature shows that risk-reducing mastectomy does not affect survival, although it lowers breast cancer incidence. Close surveillance, cancer screening, and chemoprevention methods should have priority.
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Affiliation(s)
- Bilal Arslan
- Department of General Surgery, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Deniz Tazeoğlu
- Department of General Surgery, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Ahmet Dağ
- Department of General Surgery, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Mustafa Berkeşoğlu
- Department of General Surgery, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Asena Ayça Özdemir
- Department of Biostatistics, Mersin University Faculty of Medicine, Mersin, Turkey
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Domingo Bretón M, Allué Cabañuz M, Castán Villanueva N, Arribas Del Amo MD, Gil Romea I, Güemes Sánchez A. CBCRisk model to determine the risk of contralateral breast cancer in sporadic breast cancer. Cir Esp 2021; 99:724-729. [PMID: 34764058 DOI: 10.1016/j.cireng.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The great majority of breast cancer (BC) cases are diagnosed in women who have no known family history of the disease and are not carriers of any risk mutation. During the past few decades an increase in the number of contralateral prophylactic mastectomy (CPM) has been produced in these patients. The CBCRisk model calculates the absolute risk of suffering from contralateral breast cancer (CBC); thus, it can be used to counselling patients with sporadic breast cancer. METHOD An observational, retrospective study including sporadic breast cancer patients treated with contralateral prophylactic mastectomy has been conducted between 2017 and 2019. A descriptive and comparative study with one variation of logistic regression has been carried out in order to identify predictive factors of occult tumors (OT) and medium/high risk damage (MHRD). Evaluation of the CBCRisk model published in 2017 and different limit values for the CPM recommendation. RESULTS 42 patients were selected. Incidence of MHRD and OT was lower than that described in the literatura (9.52%MHRD, 2.38%OT). None of the evaluated variables reached statistical significance for predicting injuries. The average value of CBCRisk 5 years ahead found in patients with pathological findings was 2.08 (DE 0.97), higher than the average value of the whole group (1.87 ± 0.91) and the subgroup without pathological findings (1.84 ± 0.91). Only values >3 for CBCRisk were considered statistically significant (P = .04) for the prediction of histological lesions. CONCLUSION Patients with sporadic breast cancer should be adequately informed about the estimated risks and benefits of undergoing a contralateral prophylactic mastectomy. The CBCRisk may be useful for the counseling of these patients, but it requires validation in larger and prospective cohorts.
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Affiliation(s)
- María Domingo Bretón
- Servicio de Cirugía General, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
| | - Marta Allué Cabañuz
- Servicio de Cirugía General, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Ismael Gil Romea
- Servicio de Cirugía General, Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Antonio Güemes Sánchez
- Servicio de Cirugía General, Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Siegel A, Bremer RC, Klein WMP, Savage SA, Loud JT, Khincha PP. Uptake and timing of bilateral and contralateral risk-reducing mastectomy in women with Li-Fraumeni syndrome. Breast Cancer Res Treat 2021. [PMID: 34652547 DOI: 10.1007/s10549-021-06410-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Women with Li-Fraumeni Syndrome (LFS) often consider risk-reducing mastectomy (RRM) due to extremely high risk of breast cancer at early ages. Data on uptake of RRM in LFS are scarce, and are inferred from experience in women with pathogenic variants (PVs) in BRCA1/2, despite differences in cancer risks. This study evaluated RRM uptake in a cohort of women with LFS. METHODS Women (n = 205) with LFS enrolled in NCI's LFS study reported lifetime cancer diagnoses and mastectomies and completed questionnaires regarding reproductive history, cancer worry and risk perceptions. A subset of women participating in an annual cancer screening study received counseling regarding RRM. RESULTS 65% (n = 71) of women diagnosed with presumed unilateral breast cancer (n = 109) underwent contralateral RRM over their lifetime. Nearly half (49%, n = 25) of the women who did not complete contralateral RRM within one year of their breast cancer diagnosis (n = 51) developed contralateral breast cancer (median interval = 6 years). Only 18.5% (n = 15) of women without breast cancer history (n = 81) underwent bilateral RRM. Median age at bilateral RRM of 39 years was sub-optimal for breast cancer risk reduction. Contralateral RRM was associated with early genetic diagnosis, participation in the screening study, and fewer prior cancers. Bilateral RRM uptake was associated with having had children, having breastfed, and high cancer worry. CONCLUSION Uptake of contralateral RRM is high in women with LFS. The frequency of contralateral breast cancer necessitates active discussion of benefits of contralateral RRM and counseling regarding bilateral RRM should be tailored to the early age at risk of breast cancer onset in LFS. There is a need for research into the survival and long-term benefits of RRM in LFS.
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11
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Park B, Kim D, Kim J, Lee BY, Yoon J, Kim SW. Attitudes toward Risk-Reducing Mastectomy and Risk-Reducing Salpingo-oophorectomy among Young, Unmarried, Healthy Women in Korea. Cancer Res Treat 2021; 54:375-382. [PMID: 34384016 PMCID: PMC9016293 DOI: 10.4143/crt.2021.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose This study investigated the attitudes toward risk-reducing mastectomy (RRM) and risk-reducing salpingo-oophorectomy (RRSO) as cancer prevention options for BRCA1/2 carriers in healthy, young, unmarried Korean women. Materials and Methods A nationally representative sample of 600 women, aged 20–39 years, completed a questionnaire on sociodemographic variables, preference for genetic testing, and intention to undergo risk-reducing surgeries after receiving information on the cancer risk of BRCA1/2 mutations and benefits of risk-reducing surgeries. Results A total of 54.7% and 57.7% had the intention to undergo RRM and RRSO, respectively, on the assumption that they were BRCA1/2 carriers. Older age and no intention to undergo genetic testing were associated with a reduced likelihood of undergoing RRM (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.14 to 0.61 for age 35–39 years and OR, 0.35; 95% CI, 0.20 to 0.62 for no intention for genetic testing) and RRSO (OR, 0.39; 95% CI, 0.19 to 0.79 for age 35–39 years and OR, 0.30; 95% CI, 0.17 to 0.53 for no intention for genetic testing). Women who chose to be single were likely to undergo risk-reducing surgeries (OR, 1.67; 95% CI, 1.07 to 2.60 for RRM and OR, 1.56; 95% CI, 1.00 to 2.44 for RRSO). Conclusion More than 50% of healthy, unmarried, young Korean women were inclined to undergo prophylactic surgeries if they were BRCA1/2 mutation carriers. Further studies on decision-making process for cancer prevention in individuals at high risk for cancer need to be conducted.
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Affiliation(s)
- Boyoung Park
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dongwon Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Jiyoung Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Bom Yi Lee
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Junghyun Yoon
- Department of Health Sciences, Hanyang University College of Medicine, Seoul, Korea
| | - Sung-Won Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
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12
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Ložar T, Žgajnar J, Perhavec A, Blatnik A, Novaković S, Krajc M. Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia. Eur J Surg Oncol 2021; 47:1900-6. [PMID: 33812767 DOI: 10.1016/j.ejso.2021.03.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/22/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia. MATERIALS AND METHODS Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed. RESULTS Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%). CONCLUSION The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.
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13
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Domingo Bretón M, Allué Cabañuz M, Castán Villanueva N, Arribas Del Amo MD, Gil Romea I, Güemes Sánchez A. CBCRisk model to determine the risk of contralateral breast cancer in sporadic breast cancer. Cir Esp 2020; 99:S0009-739X(20)30381-X. [PMID: 33358405 DOI: 10.1016/j.ciresp.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The great majority of breast cancer (BC) cases are diagnosed in women who have no known family history of the disease and are not carriers of any risk mutation. During the past few decades an increase in the number of contralateral prophylactic mastectomy (CPM) has been produced in these patients. The CBCRisk model calculates the absolute risk of suffering from contralateral breast cancer (CBC); thus, it can be used to counselling patients with sporadic breast cancer. METHOD An observational, retrospective study including sporadic breast cancer patients treated with contralateral prophylactic mastectomy has been conducted between 2017 and 2019. A descriptive and comparative study with one variation of logistic regression has been carried out in order to identify predictive factors of occult tumors (OT) and medium/high risk damage (MHRD). Evaluation of the CBCRisk model published in 2017 and different limit values for the CPM recommendation. RESULTS 42 patients were selected. Incidence of MHRD and OT was lower than that described in the literatura (9.52% MHRD, 2.38% OT). None of the evaluated variables reached statistical significance for predicting injuries. The average value of CBCRisk 5 years ahead found in patients with pathological findings was 2.08 (SD 0.97), higher than the average value of the whole group (1.87 ± 0.91) and the subgroup without pathological findings (1.84 ± 0.91). Only values ≥ 3 for CBCRisk were considered statistically significant (p = 0.04) for the prediction of histological lesions. CONCLUSION Patients with sporadic breast cancer should be adequately informed about the estimated risks and benefits of undergoing a contralateral prophylactic mastectomy. The CBCRisk may be useful for the counseling of these patients, but it requires validation in larger and prospective cohorts.
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Affiliation(s)
- María Domingo Bretón
- Servicio de Cirugía General, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - Marta Allué Cabañuz
- Servicio de Cirugía General, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | | | | | - Ismael Gil Romea
- Servicio de Cirugía General, Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Antonio Güemes Sánchez
- Servicio de Cirugía General, Unidad de Mama, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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14
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Ladd MK, Peshkin BN, Senter L, Baldinger S, Isaacs C, Segal H, Philip S, Phillips C, Shane K, Martin A, Weinstein V, Pilarski R, Jeter J, Sweet K, Hatten B, Wurtmann EJ, Phippen S, Bro D, Schwartz MD. Predictors of risk-reducing surgery intentions following genetic counseling for hereditary breast and ovarian cancer. Transl Behav Med 2020; 10:337-346. [PMID: 30418620 DOI: 10.1093/tbm/iby101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Risk-reducing mastectomy (RRM) and salpingo-oophorectomy (RRSO) are increasingly used to reduce breast and ovarian cancer risk following BRCA1/BRCA2 testing. However, little is known about how genetic counseling influences decisions about these surgeries. Although previous studies have examined intentions prior to counseling, few have examined RRM and RRSO intentions in the critical window between genetic counseling and test result disclosure. Previous research has indicated that intentions at this time point predict subsequent uptake of surgery, suggesting that much decision-making has taken place prior to result disclosure. This period may be a critical time to better understand the drivers of prophylactic surgery intentions. The aim of this study was to examine predictors of RRM and RRSO intentions. We hypothesized that variables from the Health Belief Model would predict intentions, and we also examined the role of affective factors. Participants were 187 women, age 21-75, who received genetic counseling for hereditary breast and ovarian cancer. We utilized multiple logistic regression to identify independent predictors of intentions. 49.2% and 61.3% of participants reported intentions for RRM and RRSO, respectively. Variables associated with RRM intentions include: newly diagnosed with breast cancer (OR = 3.63, 95% CI = 1.20-11.04), perceived breast cancer risk (OR = 1.46, 95% CI = 1.17-1.81), perceived pros (OR = 1.79, 95% CI = 1.38-2.32) and cons of RRM (OR = 0.81, 95% CI = 0.65-0.996), and decision conflict (OR = 0.80, 95% CI = 0.66-0.98). Variables associated with RRSO intentions include: proband status (OR = 0.28, 95% CI = 0.09-0.89), perceived pros (OR = 1.35, 95% CI = 1.11-1.63) and cons of RRSO (OR = 0.72, 95% CI = 0.59-0.89), and ambiguity aversion (OR = 0.79, 95% CI = 0.65-0.95). These data provide support for the role of genetic counseling in fostering informed decisions about risk management, and suggest that the role of uncertainty should be explored further.
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Affiliation(s)
- Mary Kathleen Ladd
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Beth N Peshkin
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Leigha Senter
- Division of Human Genetics, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Shari Baldinger
- Virgina Piper Cancer Institute, Allina Health, Minneapolis, MN
| | - Claudine Isaacs
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Hannah Segal
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Samantha Philip
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Chloe Phillips
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Kate Shane
- Division of Human Genetics, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Aimee Martin
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Veronique Weinstein
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
| | - Robert Pilarski
- Division of Human Genetics, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Joanne Jeter
- Division of Human Genetics, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Kevin Sweet
- Division of Human Genetics, Department of Internal Medicine and Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Bonnie Hatten
- Virgina Piper Cancer Institute, Allina Health, Minneapolis, MN
| | | | - Shanda Phippen
- Virgina Piper Cancer Institute, Allina Health, Minneapolis, MN
| | - Della Bro
- Virgina Piper Cancer Institute, Allina Health, Minneapolis, MN
| | - Marc D Schwartz
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.,Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC
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15
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Brown SL, Beesley H, Holcombe C, Saini P, Salmon P. Warranting the decision-maker, not the decision: How healthcare practitioners evaluate the legitimacy of patients' unprompted requests for risk-reducing mastectomy. Patient Educ Couns 2019; 102:1446-1451. [PMID: 30922623 DOI: 10.1016/j.pec.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Shared decision-making exists to reconcile healthcare practitioners' responsibilities to respect patients' autonomy whilst ensuring well-made decisions. Patients sometimes make unprompted requests for procedures that carry medical and other risks, such as risk-reducing mastectomy (RRM). Faced with pre-formed decisions into which they have had little input, it is unclear how practitioners can reconcile respecting autonomy with ensuring well-made decisions. METHODS Qualitative study of linked patient-practitioner interviews in a breast unit in North-West England. We examined how 10 practitioners addressed 19 patients' unprompted requests for RRM. RESULTS Practitioners empathised with patients' distress about cancer risk, regarded RRM as legitimate to help, but were wary of choices made 'emotionally'. Practitioners did not seek to establish whether choices were well-made but, instead, 'warranted' patients by satisfying themselves that patients were 'sensible' and 'informed' decision-makers, and thus their decisions could be trusted. Practitioners provided information, and tested patients' resolve by delaying decisions and presenting 'what if' scenarios depicting failure or harm from RRM. CONCLUSION Patients who present emotionally and with resolution can receive RRM without evidence of a well-made decision. PRACTICE IMPLICATIONS Argumentation theory proposes an ethically robust and clinically practicable approach, whereby practitioners elicit, examine and, where appropriate, challenge arguments underpinning patients' decisions.
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Affiliation(s)
- Stephen L Brown
- Department of Psychological Sciences, University of Liverpool, United Kingdom; School of Psychology, University of Adelaide, Australia.
| | - Helen Beesley
- Department of Psychological Sciences, University of Liverpool, United Kingdom
| | - Christopher Holcombe
- Department of Psychological Sciences, University of Liverpool, United Kingdom; Royal Liverpool and Broadgreen University Hospitals Trust, United Kingdom
| | - Pooja Saini
- School of Natural Sciences and Psychology, Liverpool John Moores University, United Kingdom
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, United Kingdom
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Nagura N, Hayashi N, Takei J, Yoshida A, Ochi T, Iwahira Y, Yamauchi H. Breast reconstruction after risk-reducing mastectomy in BRCA mutation carriers. Breast Cancer 2020; 27:70-6. [PMID: 31292927 DOI: 10.1007/s12282-019-00995-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Breast reconstruction is a favorable option for women with BRCA1 or BRCA2 mutations (BRCA1/2Mut+) who undergo risk-reducing mastectomy (RRM). We assessed characteristics of patients who underwent RRM, with or without breast reconstruction. METHODS We included 46 patients with BRCA1/2Mut+ who underwent RRM from July 2011 to December 2017. RESULTS Among the 46 patients who underwent RRM, 3 had not been diagnosed with breast cancer (BC) and 43 had cancer in a single breast; 33 patients (71.7%) underwent breast reconstruction with RRM; and 13 patients (28.3%) did not undergo breast reconstruction. All of 3 patients who had not been diagnosed with BC underwent bilateral RRM with breast reconstruction. There was no significant difference of clinical characteristic between patients undergoing RRM with and without breast reconstruction. However, patients who decided to undergo RRM with the current diagnosis of BC had significantly higher rates of RRM with breast reconstruction than that of patients with a past history of BC (P = 0.043). The rate of nipple-sparing mastectomy (NSM) in patients with breast reconstruction was significantly higher (28 of the 37 breasts, 75.7%) than that in patients without reconstruction (3 of the 14 breasts, 21.4%) (P < 0.001). Two patients who had complications underwent RRM with breast reconstruction, and one of them had a history of irradiation after lumpectomy. CONCLUSIONS For BRCA1/2Mut+ patients, the decision of taking RRM with the diagnosis of current BC might affect whether they undergo immediate breast reconstruction with RRM. These patients who undergo RRM with breast reconstruction preferred NSM to skin-sparing mastectomies.
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17
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Mao J, Jorm L, Sedrakyan A. Trends in Use of Risk-Reducing Mastectomy in a Context of Celebrity Decisions and Media Coverage: An Observational Study in the United States and Australia. Health Serv Res 2018; 53 Suppl 1:2682-2695. [PMID: 28944955 PMCID: PMC6056602 DOI: 10.1111/1475-6773.12774] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To examine trends in risk-reducing mastectomy (RRM) and immediate breast reconstruction in New York State and New South Wales, especially before and after Angelina Jolie's announcement of her surgery in 2013. DATA SOURCE Hospital discharge data, 2004-2014. STUDY DESIGN Trends in procedures were assessed using Poisson regression and the Cochrane-Armitage test. DATA EXTRACTION METHODS Extracted using procedure codes. PRINCIPAL FINDINGS There was an increase in RRM procedures after May 2013 in both regions, with a peak during late 2013-early 2014. The average bimonthly RRM procedures were significantly higher after Jolie's announcement than before. CONCLUSIONS In both countries, we found a substantial increase of RRM after Jolie's announcement, highlighting the impact of celebrity health care coverage on preventive surgical choice and the need for decision aids to assist patients.
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Affiliation(s)
- Jialin Mao
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
| | - Louisa Jorm
- Center for Big Data Research in HealthUniversity of New South WalesSydneyNSWAustralia
| | - Art Sedrakyan
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
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Abstract
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.
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Affiliation(s)
- Helen Krontiras
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Faculty Office Tower Suite 1153, 1720 2nd Avenue South, Birmingham, AL 35294-3411, USA.
| | - Meagan Farmer
- Department of Genetics, University of Alabama at Birmingham, Kaul Human Genetics Building, Suite 230, 720 20th Street, South Birmingham, AL 35294-0024, USA
| | - Julie Whatley
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Faculty Office Tower Suite 1153, 1720 2nd Avenue South, Birmingham, AL 35294-3411, USA
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Braude L, Kirsten L, Gilchrist J, Juraskova I. A systematic review of women's satisfaction and regret following risk-reducing mastectomy. Patient Educ Couns 2017; 100:2182-2189. [PMID: 28732648 DOI: 10.1016/j.pec.2017.06.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE A systematic review of quantitative and qualitative studies, to describe patient satisfaction and regret associated with risk-reducing mastectomies (RRM), and the patient-reported factors associated with these among women at high risk of developing breast cancer. METHODS Studies were identified using Medline, CINAHL, Embase and PsycInfo databases (1995-2016). Data were extracted and crosschecked for accuracy. Article quality was assessed using standardised criteria. RESULTS Of the 1657 unique articles identified, 30 studies met the inclusion criteria (n=23 quantitative studies, n=3 qualitative studies, n=4 mixed-method studies). Studies included were cross-sectional (n=23) or retrospective (n=7). General satisfaction with RRM, decision satisfaction and aesthetic satisfaction were generally high, although some women expressed regret around their decision and dissatisfaction with their appearance. Factors associated with both patient satisfaction and regret included: post-operative complications, body image changes, psychological distress and perceived inadequacy of information. CONCLUSION While satisfaction with RRM was generally high, some women had regrets and expressed dissatisfaction. Future research is needed to further explore RRM, and to investigate current satisfaction trends given the ongoing improvements to surgical and clinical practice. PRACTICE IMPLICATIONS Offering pre-operative preparation, decisional support and continuous psychological input may help to facilitate satisfaction with this complex procedure.
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Affiliation(s)
- Lucy Braude
- School of Psychology, The University of Sydney, Sydney, Australia.
| | - Laura Kirsten
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, The University of Sydney, Sydney, Australia; Nepean Cancer Care Centre, Sydney West Cancer Network, Sydney, Australia
| | | | - Ilona Juraskova
- School of Psychology, The University of Sydney, Sydney, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, The University of Sydney, Sydney, Australia
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20
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Yamauchi H, Nakagawa C, Kobayashi M, Kobayashi Y, Mano T, Nakamura S, Arai M. Cost-effectiveness of surveillance and prevention strategies in BRCA1/2 mutation carriers. Breast Cancer 2018; 25:141-50. [PMID: 29019095 DOI: 10.1007/s12282-017-0803-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cost-effectiveness analysis is an important aspect of healthcare, including in Japan, where preventive measures for BRCA1/2 mutation carriers are not covered by health insurance. METHODS We developed Markov models in a simulated cohort of women aged 35-70 years, and compared outcomes of surveillance with risk-reducing mastectomy (RRM) at age 35, risk-reducing salpingo-oophorectomy (RRSO) at age 45, and both (RRM&RRSO). We used breast and ovarian cancer incidences and adverse event rates from the previous studies, adjuvant chemotherapy, and hormonal therapy rates from the Hereditary Breast and Ovarian Cancer Registration 2015 in Japan, mortality rates from the National Cancer Center Hospital, Japan Society of Clinical Oncology, and Ministry of Health, Labour and Welfare, and direct costs from St. Luke's International Hospital and Keio University Hospital. We used previously published preference ratings of women without known high risk to adjust survival for quality of life. The discount rate was 2%. RESULTS Compared with surveillance, RRSO and RRM&RRSO were dominant (both cost-saving and more effective), and RRM was cost-effective in BRCA1 mutation carriers, while RRM and RRM&RRSO were dominant and RRSO was cost-effective in BRCA2. Among the four strategies including surveillance, RRM&RRSO and RRM were the most cost-effective in BRCA1 and BRCA2 mutation carriers, respectively. CONCLUSIONS With quality adjustment, RRM, RRSO, and RRM&RRSO were all cost-effective preventive strategies in BRCA1/2 mutation carriers, with RRM&RRSO being the most cost-effective in BRCA1 and RRM in BRCA2. This result supports the inclusion of insurance coverage for BRCA mutation carriers in Japan.
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Braude L, Laidsaar-Powell R, Gilchrist J, Kirsten L, Juraskova I. An exploration of Australian psychologists' role in assessing women considering risk-reducing or contralateral prophylactic mastectomy. Breast 2017; 32:105-111. [PMID: 28135658 DOI: 10.1016/j.breast.2017.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES Given increasing rates of risk-reducing mastectomies (RRM) and contralateral prophylactic mastectomies (CPM), and the potentially significant psychological sequelae of this irreversible procedure, health professionals (HPs) regularly refer patients to psychologists for pre-operative assessment and support. This is the first study to provide qualitative insights from HPs into the role of psychologists who are working with women considering RRM or CPM. MATERIALS AND METHODS 24 HPs (psychologists, surgeons, breast care nurses and genetic counsellors) experienced in treating patients before or after RRM/CPM completed semi-structured interviews (n = 15) or participated in a focus group (n = 10). Interviews were qualitatively analysed using Framework methods. RESULTS Qualitative analysis revealed four interconnected themes: (1) perceived patient motivation to undergo RRM/CPM; (2) HP reasons for psychologist referral; (3) role of the psychologist; and (4) value of psychologist involvement. The reported psychologist role included: mental health assessment, checking understanding of information, ensuring informed decision-making, preparation for the procedure, and management of post-surgical challenges. CONCLUSION Psychologists are perceived by HPs to have a key role in the multi-disciplinary care of patients considering RRM or CPM.
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Affiliation(s)
- Lucy Braude
- School of Psychology, The University of Sydney, NSW, Australia.
| | - Rebekah Laidsaar-Powell
- School of Psychology, The University of Sydney, NSW, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW, Australia
| | - Jemma Gilchrist
- Specialist Oncology Services, Norwest Private Hospital, NSW, Australia
| | - Laura Kirsten
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW, Australia; Nepean Cancer Care Centre, Sydney West Cancer Network, NSW, Australia
| | - Ilona Juraskova
- School of Psychology, The University of Sydney, NSW, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, NSW, Australia
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Myklebust M, Gjengedal E, Strømsvik N. Experience of Norwegian Female BRCA1 and BRCA2 Mutation-Carrying Participants in Educational Support Groups: a Qualitative Study. J Genet Couns 2016; 25:1198-1206. [PMID: 27091466 DOI: 10.1007/s10897-016-9954-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 03/28/2016] [Indexed: 11/24/2022]
Abstract
Women identified as BRCA1 and BRCA2 mutation carriers are advised to manage their cancer risk through intensive screening programs and/or by undergoing risk-reducing surgery. The aim of this study was to explore and describe the experiences of female BRCA1/2 mutation carriers living with cancer risk and their experiences with participation in educational support groups (ESG). This qualitative study enrolled 17 (10 + 7) ESG participants in two different ESGs. The focus group interviews were performed immediately prior to and following two ESGs. The data were analyzed using John Knodel's (1993) practical approach. Three main themes were identified; the women's expectation and experience with ESG, the feeling of loneliness and isolation, and the feelings of living with "something else." In this paper we have focused on one of the main themes- the women's expectation and experience with ESG. This main theme presents four subthemes: the women's need for unambiguous, clear and unified information from health professionals, the need for social support, the important role of the patient representative, and increased knowledge potentially raising concern. Participation in an ESG for women with BRCA1 and BRCA2 mutations can provide relevant information and support in the decision-making process related to risk-reducing surgery.
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Affiliation(s)
- Marion Myklebust
- Northern Norway Familial Cancer Center, Department of Medical Genetics, University Hospital of North-Norway, Tromsø, Norway
| | - Eva Gjengedal
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Faculty of Health and Social Care, Molde University College, Molde, Norway
| | - Nina Strømsvik
- Northern Norway Familial Cancer Center, Department of Medical Genetics, University Hospital of North-Norway, Tromsø, Norway. .,Faculty of Health Science, The Arctic University of Norway, Tromsø, Norway.
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Harmsen MG, Hermens RPMG, Prins JB, Hoogerbrugge N, de Hullu JA. How medical choices influence quality of life of women carrying a BRCA mutation. Crit Rev Oncol Hematol 2015; 96:555-68. [PMID: 26299336 DOI: 10.1016/j.critrevonc.2015.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 05/19/2015] [Accepted: 07/16/2015] [Indexed: 12/24/2022] Open
Abstract
Germline mutations in BRCA1 and BRCA2 genes were discovered twenty years ago. Female BRCA mutation carriers have an increased risk of breast and ovarian cancer at a relatively young age. Several choices have to be made with respect to cancer risk management, and consequences of these choices may affect quality of life. A review of the literature was performed to evaluate quality of life in unaffected BRCA mutation carriers and the influence of these medical choices. Overall, general quality of life appears not to be permanently affected in BRCA mutation carriers or by their choices. Risk-reducing salpingo-oophorectomy and its subsequent premature menopause affect (menopause specific) quality of life most. Hormone replacement therapy does not fully alleviate climacteric symptoms and therefore, there is a strong need for alternative strategies to reduce ovarian cancer risk and/or for improvements in postoperative care. Future research should focus on these needs.
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Affiliation(s)
- Marline G Harmsen
- Department of Obstetrics & Gynaecology, Radboud University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Rosella P M G Hermens
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Judith B Prins
- Department of Medical Psychology, Radboud University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Joanne A de Hullu
- Department of Obstetrics & Gynaecology, Radboud University Medical Center Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Hagen AI, Mæhle L, Vedå N, Vetti HH, Stormorken A, Ludvigsen T, Guntvedt B, Isern AE, Schlichting E, Kleppe G, Bofin A, Gullestad HP, Møller P. Risk reducing mastectomy, breast reconstruction and patient satisfaction in Norwegian BRCA1/2 mutation carriers. Breast 2013; 23:38-43. [PMID: 24210736 DOI: 10.1016/j.breast.2013.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 10/04/2013] [Accepted: 10/12/2013] [Indexed: 01/31/2023] Open
Abstract
The aim of this study was to evaluate the outcome of risk-reducing mastectomy in BRCA1/2 mutation carriers with and without breast cancer. Uptake, methods of operation and reconstruction, complications, patient satisfaction and histopathological findings were registered at all five departments of genetics in Norway. Data from 267 affected and unaffected BRCA1/2 mutation carriers were analyzed, including a study-specific questionnaire returned by 178 mutation carriers. There was a steady increase in the uptake of risk-reducing mastectomies during the study period. Complications were observed in 106/266 (39.7%) women. Patient satisfaction was high. The majority of women expressed great relief after risk-reducing mastectomy and would have chosen the same option again.
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Affiliation(s)
- Anne Irene Hagen
- Department of Breast and Endocrine Surgery, Trondheim University Hospital, Trondheim, Norway; Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Lovise Mæhle
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Nina Vedå
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Hildegunn Høberg Vetti
- Western Norway Familial Cancer Center, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
| | - Astrid Stormorken
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Trond Ludvigsen
- Department of Pathology and Medical Genetics, Trondheim University Hospital, Trondheim, Norway
| | - Bente Guntvedt
- Department of Medical Genetics, University Hospital of North Norway, Tromsø, Norway
| | - Anne Elisabeth Isern
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Teres Stokkan, Teres Medical Group, Trondheim, Norway
| | - Ellen Schlichting
- Department of Breast and Endocrine Surgery, Oslo University Hospital, Oslo, Norway
| | - Geir Kleppe
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
| | - Anna Bofin
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hans Petter Gullestad
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Pål Møller
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
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Gahm J, Hansson P, Brandberg Y, Wickman M. Breast sensibility after bilateral risk-reducing mastectomy and immediate breast reconstruction: a prospective study. J Plast Reconstr Aesthet Surg 2013; 66:1521-7. [PMID: 23953096 DOI: 10.1016/j.bjps.2013.06.054] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 06/20/2013] [Accepted: 06/29/2013] [Indexed: 11/28/2022]
Abstract
The demand for risk-reducing mastectomy (RRM) to avoid breast cancer has increased over the last several years, and knowledge of the outcome after this prophylactic surgical procedure is important. The primary aim of this study was to prospectively compare breast sensibility before and after RRM in a consecutive series of women. The study also investigated whether the nipples were less numb if the nipple areola complexes (NACs) were spared compared with regrafted nipple tips. Forty-six women who selected bilateral RRM with immediate reconstruction using implants at the Karolinska University Hospital, Solna, Stockholm, Sweden, were included in the study. The median patient age at the time of surgery was 39 years (range 26-58). All patients were evaluated preoperatively and at least 2 years postoperatively (median 29 months). Tactile, thermal and nociceptive cutaneous sensibilities were studied with quantitative techniques. The patients at the postoperative evaluation completed a questionnaire about subjective feelings in both breasts. The results showed that breast sensibility is significantly impaired after RRM. Additionally, the ability to experience sexual sensations in the breast is often lost. An NAC-sparing surgery did not result in better nipple sensibility.
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Affiliation(s)
- Jessica Gahm
- Department of Molecular Medicine and Surgery, Reconstructive Plastic Surgery, Karolinska Institutet, Stockholm, Sweden.
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Abstract
Risk-reducing mastectomy (RRM) confers 90-95% decreased risk of breast cancer, and may reduce mortality, especially in high-risk groups such as BRCA carriers. Risk of occult disease in RRM specimen is ~5%. This demands axillary staging: sentinel lymph node (SLN) biopsy is no longer possible, axillary clearance confers significant risks and may prove negative. Contemporaneous SLN biopsy allows axillary staging with minimal further dissection. Women undergoing RRM and SLN biopsy between June 2005 and July 2010 were reviewed retrospectively from our prospectively maintained database of 1,522 SLN procedures in 1,498 patients. SLN(s) localized using routine tracer methods. SLNs and mastectomy specimens underwent routine histologic examination. Eighty-three RRMs with SLN biopsy were performed in 71 patients (12 bilateral). Indications for RRM: contralateral invasive (55), in situ (5) disease, BRCA 1/2 mutation (12), and strong family history (10). Mean number of SLNs: 1.35. Occult disease was detected in four cases (4.8%), with one case of occult invasive lobular carcinoma (1.2%). Remaining occult disease was lobular in situ neoplasia (LISN). SLNs were negative in all cases. Our findings are comparable to those in the literature: 4.8% rate of occult disease overall, 1.2% invasive. The significant risk with SLN biopsy is lymphoedema, quoted around 7%. We have had no reports of symptomatic lymphoedema in patients undergoing RRM and SLN biopsy. We propose that SLN at the time of mastectomy requires only limited further dissection, and confers minimal risk compared with secondary axillary surgery.
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Affiliation(s)
- Amy Burger
- Department of Breast Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK
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Francke U, Dijamco C, Kiefer AK, Eriksson N, Moiseff B, Tung JY, Mountain JL. Dealing with the unexpected: consumer responses to direct-access BRCA mutation testing. PeerJ 2013; 1:e8. [PMID: 23638402 PMCID: PMC3628894 DOI: 10.7717/peerj.8] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/23/2012] [Indexed: 01/05/2023] Open
Abstract
Background. Inherited BRCA gene mutations convey a high risk for breast and ovarian cancer, but current guidelines limit BRCA mutation testing to women with early-onset cancer and relatives of mutation-positive cases. Benefits and risks of providing this information directly to consumers are unknown. Methods. To assess and quantify emotional and behavioral reactions of consumers to their 23andMe Personal Genome Service® report of three BRCA mutations that are common in Ashkenazi Jews, we invited all 136 BRCA1 and BRCA2 mutation-positive individuals in the 23andMe customer database who had chosen to view their BRCA reports to participate in this IRB-approved study. We also invited 160 mutation-negative customers who were matched for age, sex and ancestry. Semi-structured phone interviews were completed for 32 mutation carriers, 16 women and 16 men, and 31 non-carriers. Questions addressed personal and family history of cancer, decision and timing of viewing the BRCA report, recollection of the result, emotional responses, perception of personal cancer risk, information sharing, and actions taken or planned. Results. Eleven women and 14 men had received the unexpected result that they are carriers of a BRCA1 185delAG or 5382insC, or BRCA2 6174delT mutation. None of them reported extreme anxiety and four experienced moderate anxiety that was transitory. Remarkably, five women and six men described their response as neutral. Most carrier women sought medical advice and four underwent risk-reducing procedures after confirmatory mutation testing. Male carriers realized that their test results implied genetic risk for female relatives, and several of them felt considerably burdened by this fact. Sharing mutation information with family members led to screening of at least 30 relatives and identification of 13 additional carriers. Non-carriers did not report inappropriate actions, such as foregoing cancer screening. All but one of the 32 mutation-positive participants appreciated learning their BRCA mutation status. Conclusions. Direct access to BRCA mutation tests, considered a model for high-risk actionable genetic tests of proven clinical utility, provided clear benefits to participants. The unexpected information demonstrated a cascade effect as relatives of newly identified carriers also sought testing and more mutation carriers were identified. Given the absence of evidence for serious emotional distress or inappropriate actions in this subset of mutation-positive customers who agreed to be interviewed for this study, broader screening of Ashkenazi Jewish women for these three BRCA mutations should be considered.
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Affiliation(s)
- Uta Francke
- 23andMe, Inc. , Mountain View, CA , USA ; Department of Genetics , Stanford University School of Medicine , Stanford, CA , USA
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