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Aesthetic Plastic Surgery Apr 2020Many breast cancer patients remove their contralateral breast unaffected by cancer, commonly referred to as contralateral prophylactic mastectomy (CPM). CPM has been...
INTRODUCTION
Many breast cancer patients remove their contralateral breast unaffected by cancer, commonly referred to as contralateral prophylactic mastectomy (CPM). CPM has been extensively studied and does not improve survival in patients without deleterious genetic mutation or lobular histology. Despite these limited indications, CPM rates have increased recently. We observed CPM trends in our county safety-net hospital.
METHODS
We performed a retrospective review of women treated for breast cancer who underwent bilateral mastectomy in our institution.
RESULTS
We analyzed 100 CPMs: 51% (n = 51) had bilateral breast MRI before CPM, 54% (n = 54) had genetic testing prior to CPM, and 56% (n = 30) had a deleterious genetic result. Another 12% (n = 12) had lobular histology as the primary determinant for CPM. Of patients without genetic mutation or lobular histology, 13% (n = 13) had suspicious MRI findings in the CPM side that drove the decision for CPM. Forty-seven percent (n = 47) had reconstructive surgery documented.
CONCLUSION
Only 42% (n = 42) of patients who underwent CPM had a documented justifiable medical reason. In the future, physician and patient education may decrease unindicated CPM. We also found that 13% of women without a medical indication chose CPM based on suspicious MRI findings, while only 8% of these MRI findings were malignant.
LEVEL OF EVIDENCE IV
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Topics: Breast; Breast Neoplasms; Female; Humans; Mastectomy; Prophylactic Mastectomy; Retrospective Studies
PubMed: 31853610
DOI: 10.1007/s00266-019-01582-4 -
Seminars in Plastic Surgery Nov 2019There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent... (Review)
Review
There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.
PubMed: 31632204
DOI: 10.1055/s-0039-1696964 -
Journal of Plastic, Reconstructive &... Jun 2022Women with an increased hereditary risk of breast cancer can undergo risk-reducing prophylactic mastectomy. However, there is a balance between how much subcutaneous...
BACKGROUND
Women with an increased hereditary risk of breast cancer can undergo risk-reducing prophylactic mastectomy. However, there is a balance between how much subcutaneous tissue should be resected to achieve maximal reduction of glandular tissue, while leaving viable skin flaps.
METHODS
Forty-five women previously operated with prophylactic mastectomy underwent magnetic resonance tomography (MRT) and ultrasound (US) to investigate the correlation between skin flap thickness and residual glandular tissue. Residual glandular tissue was documented as being present or not present, but not quantified, as the amount of residual glandular tissue in many cases was considered too small to make reliable volume quantifications with available tools. Since a mastectomy skin flap thickness of 5 mm is discussed as an oncologically safe thickness in the literature, this was used as a cut-off.
RESULTS
Following prophylactic mastectomy, residual glandular tissue was detected in 39.3% of all breasts and 27.9% of all the breast quadrants examined by MRT, and 44.1% of all breasts and 21.7% of all the breast quadrants examined by US. Residual glandular tissue was detected in 6.9% of the quadrants in skin flaps ≤ 5 mm and in 37.5% of the quadrants in skin flaps > 5 mm (OR 3.07; CI = 1.41-6.67; p = 0.005). Furthermore, residual glandular tissue increased significantly already when the skin flap thickness exceeded 7 mm.
CONCLUSIONS
This study highlights that complete removal of glandular breast tissue during a mastectomy is difficult and suggests that this is an unattainable goal. We demonstrate that residual glandular tissue is significantly higher in skin flaps > 5 mm in comparison to skin flaps ≤ 5 mm, and that residual glandular tissue increases significantly already when the flap thickness exceeds 7 mm.
Topics: Breast Neoplasms; Female; Humans; Magnetic Resonance Imaging; Mammaplasty; Mastectomy; Prophylactic Mastectomy; Surgical Flaps
PubMed: 35177362
DOI: 10.1016/j.bjps.2022.01.031 -
JAMA Surgery Dec 2023Few studies have investigated whether prophylactic salpingo-oophorectomy (PSO) for patients with previously resected breast cancer who carry pathogenic germline BRCA1 or...
IMPORTANCE
Few studies have investigated whether prophylactic salpingo-oophorectomy (PSO) for patients with previously resected breast cancer who carry pathogenic germline BRCA1 or BRCA2 variants is associated with a reduced risk of cancer-specific death.
OBJECTIVE
To assess the association of PSO and prophylactic mastectomy (PM) with prognosis after quadrantectomy or mastectomy as primary treatment for patients with BRCA1 or BRCA2 breast cancer.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study was performed in a single-institution, tertiary referral center. Consecutive patients with invasive breast cancer treated surgically between 1972 and 2019 were recruited and followed up prospectively after they were found to carry the BRCA1 or BRCA2 gene variant. The data analysis was performed between April 2022 and July 2023.
EXPOSURE
Following breast surgery, some patients underwent PSO, PM, or both, whereas others did not.
MAIN OUTCOMES AND MEASURES
The primary study end point was overall survival as measured by the Kaplan-Meier method. Secondary end points were crude cumulative incidence of breast cancer-specific mortality, ipsilateral breast tumor recurrence (IBTR), contralateral breast cancer, ovarian cancer, and ovarian cancer-specific mortality.
RESULTS
Of 480 patients included in the cohort (median age at initial surgery, 40.0 years; IQR, 34.0-46.0 years), PSO was associated with a significantly reduced risk of death (hazard ratio [HR], 0.40; 95% CI, 0.25-0.64; P < .001). This reduction was most evident for patients carrying the BRCA1 variant (HR, 0.35; 95% CI, 0.20-0.63; P = .001), those with triple-negative disease (HR, 0.21; 95% CI, 0.09-0.46; P = .002), and those with invasive ductal carcinoma (HR, 0.51; 95% CI, 0.31-0.84; P = .008). Prophylactic salpingo-oophorectomy was not associated with risk of contralateral breast cancer or IBTR. Initial or delayed PM was associated with a reduced risk of IBTR but not with overall survival or breast cancer-specific mortality.
CONCLUSIONS
The study findings suggest that PSO should be offered to all patients with BRCA1/2 breast cancer who undergo surgery with curative intent to reduce risk of death. In particular, PSO should be offered to patients with the BRCA1 variant at the time of breast surgery.
Topics: Female; Humans; Adult; Breast Neoplasms; Salpingo-oophorectomy; BRCA1 Protein; Mastectomy; Retrospective Studies; BRCA2 Protein; Genes, BRCA1; Neoplasm Recurrence, Local; Ovariectomy; Ovarian Neoplasms; Mutation
PubMed: 37792368
DOI: 10.1001/jamasurg.2023.4770 -
Journal of Clinical Oncology : Official... Nov 2022Women with unilateral breast cancer are increasingly opting for the removal of not only the involved breast, but also for the removal of the opposite uninvolved breast...
PURPOSE
Women with unilateral breast cancer are increasingly opting for the removal of not only the involved breast, but also for the removal of the opposite uninvolved breast (contralateral prophylactic mastectomy [CPM]), although the risk of contralateral breast cancer (CBC) has decreased in recent years. Models to predict the absolute risk of CBC can help a woman decide whether to undergo CPM. Our objective is to illustrate that a better decision can be made if the patient and doctor also have estimates of the absolute risks of regional and distant recurrences and mortality from non-breast cancer causes.
MATERIALS AND METHODS
We based our analyses on two published models for CBC and published information on the hazards of regional and distant recurrences and non-breast cancer mortality. Assuming that CPM eliminates CBC but has no effect on other events, we calculated how much CPM reduces a woman's CBC risk and total risk from all these events for 10 hypothetical women with various subtypes of breast cancer and risk factors.
RESULTS
The risk of CBC and total risk vary greatly, depending on the breast cancer subtype. In some cases, a decision for or against CPM can be based on CBC risk alone, but in others, additional consideration of total risk may cause a woman to decline CPM.
CONCLUSION
There is a potential to develop more informative tools for deciding on CPM. Realizing this potential will require more and better data to validate existing models of absolute CBC risk and to characterize the hazards of regional and distant recurrences and deaths from non-breast cancer causes for women with various subtypes of breast cancers and risk factors.
Topics: Female; Humans; Mastectomy; Prophylactic Mastectomy; Breast Neoplasms; Risk Factors; Decision Making
PubMed: 35759730
DOI: 10.1200/JCO.21.02782 -
Annals of Surgical Oncology Nov 2023The impact of ATM, CHEK2, and PALB2, the three most prevalent moderate-risk breast cancer genes, on surgical decision making is not well known.
BACKGROUND
The impact of ATM, CHEK2, and PALB2, the three most prevalent moderate-risk breast cancer genes, on surgical decision making is not well known.
METHODS
Our retrospective study included patients with resectable non-metastatic breast cancer who underwent multigene panel testing between July 2014 and January 2020 with at least one genetic alteration (pathogenic or variant of uncertain significance [VUS] in ATM [n = 49], CHEK [n = 57], or PALB2 [n = 27]). Our objectives were to determine the rate of contralateral prophylactic mastectomy (CPM) and the rate of bilateral breast cancer. Univariable analyses (UVA) and multivariable analyses (MVA) were performed to identify factors associated with CPM and bilateral breast cancer.
RESULTS
The rate of CPM was 39% (n = 49/127), with 54% (n = 25/46) of patients with a pathogenic mutation and 30% (n = 24/81) of patients with a VUS choosing CPM. On MVA, premenopausal status (odds ratio [OR] 3.46) and a pathogenic alteration (OR 3.01) were associated with increased use of CPM. Bilateral disease was noted in 16% (n = 22/138). Patients with pathogenic mutations had a 22% (n = 11/51) incidence of bilateral breast cancer, while patients with VUS had a 13% (n = 11/87) incidence, although this was not statistically significant on UVA or MVA. On MVA, premenopausal status was associated with a decreased risk of bilateral disease (OR 0.33, p = 0.022). During follow-up, a breast cancer event occurred in 16% (n = 22/138).
CONCLUSIONS
Our study identified a high rate of CPM among those with ATM, CHEK2, and PALB2 alterations, including VUS. Further studies are needed to clarify reasons for CPM among patients with moderate-risk alterations.
Topics: Humans; Female; Mastectomy; Breast Neoplasms; Prophylactic Mastectomy; Retrospective Studies; Mutation
PubMed: 37661222
DOI: 10.1245/s10434-023-14141-8 -
JAMA Surgery Jun 2021Rates of bilateral mastectomy continue to increase in average-risk women with unilateral in situ and invasive breast cancer. Contralateral prophylactic mastectomy rates... (Review)
Review
IMPORTANCE
Rates of bilateral mastectomy continue to increase in average-risk women with unilateral in situ and invasive breast cancer. Contralateral prophylactic mastectomy rates increased from 5% to 12% of all operations for breast cancer in the US from 2004 to 2012. Among women having mastectomy, rates of contralateral prophylactic mastectomy have increased from less than 2% in 1998 to 30% in 2012.
OBSERVATIONS
The increased use of breast magnetic resonance imaging and genetic testing has marginally increased the number of candidates for bilateral mastectomy. Most bilateral mastectomies are performed on women who are at no special risk for contralateral cancer. The true risk of contralateral breast cancer is not associated with the decision for contralateral prophylactic mastectomy; rather, the clinical factors associated with the probability of distant recurrence are associated with bilateral mastectomy. Several changes in society and health care delivery appear to act concurrently and synergistically. First, the anxiety engendered by a fear of cancer recurrence is focused on the contralateral cancer because this is most easily conceptualized and provides a ready target that can be acted upon. Second, the modern woman with breast cancer is supported by the surgeon and the social community of breast cancer survivors. Surgeons want to respect patient autonomy, despite guidelines discouraging bilateral mastectomy, and most women have their expenses covered by a third-party payer. Satisfaction with the results is high, but the association with improved psychosocial well-being remains to be fully understood.
CONCLUSIONS AND RELEVANCE
Reducing the use of medically unnecessary contralateral prophylactic mastectomy in women with nonhereditary, unilateral breast cancer requires a social change that addresses patient-, physician-, cultural-, and systems-level enabling factors. Such a transformation begins with educating clinicians and patients. The concerns of women who want preventive contralateral mastectomy must be explored, and women need to be informed of the anticipated benefits (or lack thereof) and risks. Areas requiring further study are considered.
Topics: Female; Humans; Patient Preference; Patient Selection; Practice Patterns, Physicians'; Prophylactic Mastectomy; Unilateral Breast Neoplasms
PubMed: 33566074
DOI: 10.1001/jamasurg.2020.6664 -
Annals of Surgical Oncology Nov 2023Contralateral prophylactic mastectomy (CPM) is recommended for BRCA mutation carriers; its use in noncarriers relies on patient choice. We characterized differences in...
INTRODUCTION
Contralateral prophylactic mastectomy (CPM) is recommended for BRCA mutation carriers; its use in noncarriers relies on patient choice. We characterized differences in satisfaction and well-being after CPM between BRCA carriers and noncarriers.
METHODS
BREAST-Q data were obtained before and after CPM with immediate reconstruction performed at a single institution from 2016 to 2022. Associations between BRCA status and satisfaction with breasts, psychosocial well-being, and sexual well-being were assessed, with adjustment for preoperative scores and relevant confounders.
RESULTS
In total, 149 BRCA carriers and 842 noncarriers were included. Response rates varied over time (preoperative, 56%; 6 months, 78%; 1 year, 51%; 2 years, 52%; 3 years, 59%). BRCA carriers were younger (p < 0.001), with a higher rate of neoadjuvant chemotherapy (p < 0.001). More noncarriers had HR+/HER2- tumors (p < 0.001) and underwent endocrine therapy (p < 0.001). Baseline satisfaction with breasts was higher among BRCA carriers (median [interquartile range] score, 70 [53-82] vs. 58 [48-70]; p = 0.006); psychosocial (p = 0.20) and sexual (p = 0.14) well-being were not significantly different between groups. BRCA carriers had a greater decrease in satisfaction with breasts (p = 0.04) and psychological well-being (p = 0.05) from baseline to 6 months; decrease in sexual well-being (p = 0.38) was not significantly different between groups. On univariate and multivariable analyses, BRCA status was not associated with satisfaction with breasts, sexual well-being, or psychosocial well-being.
CONCLUSIONS
Satisfaction and well-being were similar between BRCA carriers and noncarriers treated with CPM. Relative to noncarriers, BRCA carriers experienced a greater decline in satisfaction with breasts and psychological well-being at 6 months after CPM.
Topics: Humans; Female; Mastectomy; Prophylactic Mastectomy; Breast Neoplasms; Mutation; Personal Satisfaction; Patient Satisfaction
PubMed: 37581851
DOI: 10.1245/s10434-023-14086-y -
Clinical Breast Cancer Jun 2023This study aims to capture clinical and surgical practice patterns of patients with deleterious mutations in partner and localizer of BRCA2 (PALB2), checkpoint kinase 2...
BACKGROUND
This study aims to capture clinical and surgical practice patterns of patients with deleterious mutations in partner and localizer of BRCA2 (PALB2), checkpoint kinase 2 (CHEK2) and ataxia telangiesctasia mutated (ATM) genes.
MATERIALS AND METHODS
This study is a retrospective chart review of patients with PALB2, CHEK2 or ATM mutations. Patient demographics, testing indications, management decisions, and surveillance strategies were recorded.
RESULTS
Sixty-two patients were found to have deleterious mutations: 14 (23%) with a PALB2 mutation, 30 (48%) with a CHEK2 mutation, and 18 (29%) patients with an ATM mutation. Thirty-one (50%) patients have a history of breast cancer. Twenty-three patients were diagnosed and treated prior to genetic testing while 8 patients learned of their mutation status and breast cancer diagnosis simultaneously. Of these 8 patients, 4 sought treatment at our institution, 3 underwent bilateral mastectomy, and 1 patient opted for lumpectomy and surveillance. Thirty-one patients had no history of breast cancer. After genetic diagnosis, 3 of the 9 patients who continued clinical follow-up proceeded with bilateral prophylactic mastectomy within 2 years. Clinical surveillance continued for 23 months on average.
CONCLUSION
Most patients who learned of their genetic and breast cancer diagnoses simultaneously underwent bilateral mastectomy, whereas only a third of patients without cancer opted for bilateral prophylactic mastectomy.
Topics: Humans; Female; Breast Neoplasms; Checkpoint Kinase 2; Retrospective Studies; Fanconi Anemia Complementation Group N Protein; Genetic Predisposition to Disease; Mastectomy; Mutation; Ataxia; Ataxia Telangiectasia Mutated Proteins
PubMed: 36966080
DOI: 10.1016/j.clbc.2023.02.004 -
Medicina (Kaunas, Lithuania) Mar 2024Breast cancer remains a significant contributor to morbidity and mortality within oncology. Risk factors, encompassing genetic and environmental influences,... (Review)
Review
Breast cancer remains a significant contributor to morbidity and mortality within oncology. Risk factors, encompassing genetic and environmental influences, significantly contribute to its prevalence. While germline mutations, notably within the BRCA genes, are commonly associated with heightened breast cancer risk, a spectrum of other variants exists among affected individuals. Diagnosis relies on imaging techniques, biopsies, biomarkers, and genetic testing, facilitating personalised risk assessment through specific scoring systems. Breast cancer screening programs employing mammography and other imaging modalities play a crucial role in early detection and management, leading to improved outcomes for affected individuals. Regular screening enables the identification of suspicious lesions or abnormalities at earlier stages, facilitating timely intervention and potentially reducing mortality rates associated with breast cancer. Genetic mutations guide screening protocols, prophylactic interventions, treatment modalities, and patient prognosis. Prophylactic measures encompass a range of interventions, including chemoprevention, hormonal inhibition, oophorectomy, and mastectomy. Despite their efficacy in mitigating breast cancer incidence, these interventions carry potential side effects and psychological implications, necessitating comprehensive counselling tailored to individual cases.
Topics: Humans; Female; Breast Neoplasms; Romania; Early Detection of Cancer; Prophylactic Mastectomy; Mammography; Risk Factors
PubMed: 38674216
DOI: 10.3390/medicina60040570