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Breast (Edinburgh, Scotland) Feb 2017BRCA mutation carriers have a very high risk of breast and ovarian cancer by age 70, in the ranges 47%-66% and 40%-57%, respectively. Additionally, women with BRCA... (Review)
Review
BRCA mutation carriers have a very high risk of breast and ovarian cancer by age 70, in the ranges 47%-66% and 40%-57%, respectively. Additionally, women with BRCA mutation-associated breast cancer also have an elevated risk of other or secondary malignancies. Fortunately, the breast and ovarian cancer outcome for BRCA1/2 mutation carriers is at least as good as for non-carriers with chemoprevention, prophylactic surgeries and appropriate use of therapies. Therefore, identification of those who might have a mutation is important so that genetic counseling, testing, screening and prevention strategies can be applied in a timely manner. This article reviews the impact of genetic testing in general, timing of genetic testing after diagnosis and prior knowledge of mutation status in BRCA carriers with newly diagnosed breast cancer. Additionally, risk-reducing surgeries including the prophylactic contralateral mastectomy, and bilateral salpingo-oophorectomy and the sensitivity of BRCA-defective breast cancer cell lines to differential chemotherapeutic agents will be discussed.
Topics: Breast Neoplasms; Chemoprevention; Female; Genes, BRCA1; Genes, BRCA2; Genetic Testing; Hormone Replacement Therapy; Humans; Mutation; Ovarian Neoplasms; Ovariectomy; Prophylactic Mastectomy; Reproductive Behavior; United States; Watchful Waiting
PubMed: 27931006
DOI: 10.1016/j.breast.2016.11.021 -
Breast Care (Basel, Switzerland) Dec 2014Unlike the general decrease in invasive oncologic care, the trend for prophylactic bilateral mastectomy in healthy women and prophylactic contralateral mastectomy in... (Review)
Review
Unlike the general decrease in invasive oncologic care, the trend for prophylactic bilateral mastectomy in healthy women and prophylactic contralateral mastectomy in women with unilateral breast cancer is steadily rising. This is even more surprising when considering that for e.g. prophylactic contralateral mastectomy no clear survival benefit has been demonstrated so far. The decision-making process around risk-reducing surgery may be influenced by several conflicting parameters such as the patient's fears and desire to achieve a survival advantage, the surgeon's financial motivations, or the oncologist's paternalistic approach to the above trend. Physicians should support their patients throughout the decision-making process, guide them through the dense fog of information, and encourage them to reconsider all options and alternatives before embarking on an irreversible surgical intervention. Healthy and diseased women should be comprehensively informed about their absolute individual risks for cancer, the benefits and harms of the surgery, alternative preventive strategies, and last but not least the competing risks of preceding carcinomas and cancer in general. Within the framework of non-directive counseling in the specialized centers of the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC), decision-making aids are being developed with grants from the Federal Ministry of Health and the German Cancer Aid to support women in making conclusive and satisfactory decisions.
PubMed: 25759620
DOI: 10.1159/000369592 -
The British Journal of Surgery Sep 2016
Topics: Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Patient Preference; Prognosis; Prophylactic Mastectomy; United States
PubMed: 27465285
DOI: 10.1002/bjs.10223 -
International Journal of Women's Health 2015The incidence of contralateral prophylactic mastectomy (CPM) has increased among women with breast cancer, despite uncertain survival benefit and a declining incidence... (Review)
Review
The incidence of contralateral prophylactic mastectomy (CPM) has increased among women with breast cancer, despite uncertain survival benefit and a declining incidence of contralateral breast cancer (CBC). Patient-related reasons for undergoing CPM include an overestimation of the risk of CBC, increased cancer worry, and a desire to improve survival. We summarize the existing literature on CBC risk and outcomes and the clinical benefit of CPM among women with unilateral breast cancer who have a low-to-moderate risk of developing a secondary cancer in the contralateral breast. Published studies were retrieved from the MEDLINE database with the keywords "contralateral breast cancer" and "contralateral prophylactic mastectomy". These include observational studies, clinical trials, survival analyses, and decision models examining the risk of CBC, the clinical and psychosocial effects of CPM, and other treatment strategies to reduce CBC risk. Studies that have evaluated CBC risk estimate it to be approximately 0.5% annually on average. Patient-related factors associated with an increased risk of CBC include carriers of BRCA1/2 mutations, young age at breast cancer, and strong family history of breast cancer in the absence of a BRCA1/2 mutation. Although CPM reduces the risk of CBC by approximately 94%, it may not provide a significant gain in overall survival and there is conflicting evidence that it improves disease-free survival among women with breast cancer regardless of estrogen receptor (ER) status. Therefore, alternative strategies such as the use of tamoxifen or aromatase inhibitors, which reduce the risk of CBC by approximately 50%, should be encouraged for eligible women with ER-positive breast cancers. Future research is needed to evaluate the impact of decision and educational tools that can be used for personalized counseling of patients regarding their CBC risk, the uncertain role of CPM, and alternative CBC risk reduction strategies.
PubMed: 25678823
DOI: 10.2147/IJWH.S52380 -
Annals of Surgical Oncology Mar 2020Neoadjuvant chemotherapy (NAC) for breast cancer increases breast-conserving surgery (BCS) rates, but many women opt for mastectomy with contralateral prophylactic...
BACKGROUND
Neoadjuvant chemotherapy (NAC) for breast cancer increases breast-conserving surgery (BCS) rates, but many women opt for mastectomy with contralateral prophylactic mastectomy (CPM). Here we evaluate factors associated with CPM use in women undergoing mastectomy post-NAC.
METHODS
A retrospective institutional NAC database review identified women with clinical stage I-III, unilateral invasive breast cancer undergoing unilateral mastectomy (UM) or CPM mastectomy from 9/2013 to 12/2017. Clinical/pathologic characteristics, imaging, and presence of contraindications to BCS post-NAC were compared, with subset analysis of BCS candidates. The multivariable analysis was adjusted for potential confounders.
RESULTS
Five hundred sixty-nine women underwent mastectomy after NAC, 297 (52%) UM and 272 (48%) CPM. On univariable analysis, younger age, BRCA+, lower pre-NAC clinical stage, pathologic complete response, and axillary surgery extent were associated with CPM (all p < 0.01). Favorable post-NAC clinical factors of no residual palpable disease, clinically negative nodes, complete response on breast imaging, and no post-NAC contraindication to BCS were also associated with CPM (all p < 0.01). On multivariable analysis, young age (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.91-0.95), lower pre-NAC stage (OR 0.51, 95% CI 0.34-0.77), and no contraindication to BCS (OR 3.12, 95% CI 2.02-4.82) were significantly associated with CPM. Among the 203 (35%) women who had no contraindications to BCS post-NAC, 145 (71%) underwent CPM. BRCA+ and family history were reasons more frequently cited for mastectomy among CPM than UM (p < 0.001).
CONCLUSIONS
CPM was performed in 48% of women undergoing mastectomy after NAC; younger women with earlier-stage cancers were more likely to undergo CPM. While increased use of CPM in women with more favorable disease is medically appropriate, our findings indicate a lost opportunity for use of BCS.
Topics: Antineoplastic Combined Chemotherapy Protocols; Breast Neoplasms; Female; Follow-Up Studies; Humans; Middle Aged; Neoadjuvant Therapy; Prognosis; Prophylactic Mastectomy; Retrospective Studies
PubMed: 31732944
DOI: 10.1245/s10434-019-08038-8 -
Breast Care (Basel, Switzerland) Oct 2020Prophylactic mastectomy is an effective approach to breast cancer risk reduction in patients at high risk. Further studies using standardized measures for quality of...
BACKGROUND
Prophylactic mastectomy is an effective approach to breast cancer risk reduction in patients at high risk. Further studies using standardized measures for quality of life are needed to better understand the effect of prophylactic mastectomy on individual patients and, thereby, allow for better patient counseling and selection.
METHODS
In this prospective study patients undergoing bilateral mastectomy were asked to complete the BREAST-Q questionnaire before and 1 year after surgery. All patients underwent bilateral mastectomy with implant-based breast reconstruction. Patient- and surgery-related information was collected in a database.
RESULTS
In total, 48 patients underwent bilateral skin-sparing mastectomy. Of these, 29 (60.4%) suffered from breast cancer. A 2-stage reconstruction with intermediate expander implantation was conducted in 19 (39.6%) patients. All patients completed the BREAST-Q questionnaire. The domain "psychosocial well-being" was significantly improved from a mean score of 74.98 preoperatively to a postoperative score of 81.56 ( = 0.021). In contrast, the domain "physical well-being" dropped -8.38 points on average to a postoperative score of 74.96 ( < 0.001). Interestingly, patients with the lowest preoperative score in the domain "satisfaction with breast" showed the greatest increase after surgery (50.31 vs. 67.25, < 0.001). On the contrary, patients with the highest preoperative values experienced the strongest decrease in satisfaction (91.60 vs. 75.27, = 0.012).
CONCLUSION
Implant-based prophylactic mastectomy leads to good quality-of-life results in patients at high risk for breast cancer. Especially, patients with a low preoperative satisfaction with their breasts have a significantly higher chance of experiencing substantial improvements in their quality of life.
PubMed: 33223996
DOI: 10.1159/000505449 -
The Journal of Surgical Research Jul 2019The aim of this study was to evaluate the trends of surgical treatments among young patients in TNM stage based on the Surveillance, Epidemiology, and End Results...
BACKGROUND
The aim of this study was to evaluate the trends of surgical treatments among young patients in TNM stage based on the Surveillance, Epidemiology, and End Results database.
MATERIALS AND METHODS
Patients aged less than 40 y diagnosed between 1998 and 2015 were enrolled, with tumors in TNM stage and not located in the central area. Differences in clinical-pathological characteristics were evaluated using chi-square tests. Multivariate logistic regression was used to measure the various factors associated with contralateral prophylactic mastectomy (CPM). Independent prognostic factors were evaluated by Cox model.
RESULTS
The total rate of breast-conserving surgery (BCS) was 51.6%, which declined from 64.5% in 1998 to 39.6% in 2015. The total rate of CPM was 22.7%, which increased from 3.7% in 1998 to 38.7% in 2014 despite a decline to 32.7% in 2015. Meanwhile, the rate of reconstruction increased in line with that of CPM, from 9.4% in 1998 to 35.0% in 2015. There was a trend of increasing use of implant-based reconstruction. Significant higher odds of CPM were found in recent year of diagnosis between 2010 and 2015 and in implant-based reconstruction. Patients undergoing CPM had similar survival outcomes compared with those undergoing BCS and unilateral mastectomy, whereas those undergoing BCS had better survival outcomes compared with those undergoing unilateral mastectomy.
CONCLUSIONS
A trend of growing preference for CPM and reconstruction was observed among young patients in early stage in recent years without survival benefits. Efforts should be made to promote efficient communication and evidence-based decision-making.
Topics: Adult; Age Factors; Breast Implantation; Breast Neoplasms; Decision Making; Female; Humans; Mastectomy, Segmental; Neoplasm Staging; Prognosis; Prophylactic Mastectomy; Retrospective Studies; SEER Program; Survival Analysis; Treatment Outcome
PubMed: 30856515
DOI: 10.1016/j.jss.2019.02.002 -
Annals of Surgery Feb 2018To reach a consensus about contralateral prophylactic mastectomy in unilateral breast cancer.
OBJECTIVE
To reach a consensus about contralateral prophylactic mastectomy in unilateral breast cancer.
SUMMARY BACKGROUND DATA
There has been a substantial increase in the number of North American women with unilateral breast cancer undergoing a therapeutic mastectomy and a contralateral prophylactic mastectomy (CPM) either simultaneously or sequentially. The purpose of this project was to create a nationally endorsed consensus statement for CPM in women with unilateral breast cancer using modified Delphi consensus methodology.
METHODS
A nationally representative expert panel of 19 general surgeons, 2 plastic surgeons, 2 medical oncologists, 2 radiation oncologists, and 1 psychologist was invited to participate in the generation of a consensus statement. Thirty-nine statements were created in 5 topic domains: predisposing risk factors for breast cancer, tumor factors, reconstruction/symmetry issues, patient factors, and miscellaneous factors. Panelists were asked to rate statements on a 7-point Likert scale. Two electronic rounds of iterative rating and feedback were anonymously completed, followed by an in-person meeting. Consensus was reached when there was at least 80% agreement.
RESULTS
Our panelists did not recommend for average risk women with unilateral breast cancer. The panel recommended CPM for women with a unilateral breast cancer and previous Mantle field radiation or a BrCa1/2 gene mutation. The panel agreed that CPM could be considered by the surgeon on an individual basis for: women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 gene, and in women who may have significant difficulty achieving symmetry after unilateral mastectomy.
CONCLUSION
Contralateral prophylactic mastectomy is rarely recommended for women with unilateral breast cancer.
Topics: Biomarkers, Tumor; Breast Neoplasms; Carcinoma, Lobular; Clinical Decision-Making; Delphi Technique; Female; Humans; Prophylactic Mastectomy; Risk Assessment
PubMed: 28594745
DOI: 10.1097/SLA.0000000000002309 -
Bulletin Du Cancer Nov 2021Women identified as high-risk for breast cancer may choose between close follow-up and radical mastectomy. Prophylactic mastectomy, as any other surgery, is associated...
INTRODUCTION
Women identified as high-risk for breast cancer may choose between close follow-up and radical mastectomy. Prophylactic mastectomy, as any other surgery, is associated with benefits and harms. The aim of this study was to assess the morbidity associated with prophylactic mastectomy and to evaluate the prevalence of occult cancers.
METHODS
All patients who underwent unilateral or bilateral prophylactic mastectomy between 2007 and 2017 in our institution were eligible for inclusion in this retrospective study. Medical history, type of surgery, occurrence of complication or reoperation and pathological reports were examined in medical charts.
RESULTS
79 women underwent prophylactic mastectomy over the studied period of which 58.2% were contralateral after breast cancer. A genetic mutation was present in 86.1% of cases. Postoperative complications occurred in 43.0% of cases. An additional surgery for medical or esthetic purpose was needed in 72.1% of cases. Occult cancer was found in 11.4% of the pathological reports. Triple negative invasive ductal carcinoma was discovered in two cases (2.5%).
DISCUSSION
Prophylactic mastectomy is the only effective preventive action against breast cancer. Women must be clearly informed of possible complications, high reoperation rate and potential pathological findings. Identifying women most at risk for breast cancer would help to better target those who will benefit most from surgery.
Topics: Adult; Aged; Breast Neoplasms; Cancer Care Facilities; Female; Genes, BRCA1; Genes, BRCA2; Humans; Middle Aged; Mutation; Neoplasms, Unknown Primary; Postoperative Complications; Prevalence; Prophylactic Mastectomy; Reoperation; Retrospective Studies; Time Factors
PubMed: 34556291
DOI: 10.1016/j.bulcan.2021.05.007 -
Annals of Surgical Oncology Jan 2023
Topics: Female; Humans; Mastectomy; Breast Neoplasms
PubMed: 36264517
DOI: 10.1245/s10434-022-12702-x