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Breast Cancer Research and Treatment Jan 2020There has been a sharp rise in the rate of contralateral prophylactic mastectomy over the last decade, despite the low incidence of new primary cancers predicted for the...
INTRODUCTION
There has been a sharp rise in the rate of contralateral prophylactic mastectomy over the last decade, despite the low incidence of new primary cancers predicted for the contralateral breast. This study compares the postoperative complication rates between the diseased breast treated with mastectomy and the contralateral breast that underwent prophylactic mastectomy, followed by immediate bilateral breast implant reconstruction. We hypothesized that there will be no difference in postoperative outcomes between prophylactic and diseased groups, as the surgical approach would be comparable.
METHODS
After IRB approval, a retrospective chart review identified consecutive unilateral breast cancer patients who underwent bilateral mastectomy and immediate breast reconstruction between May 2008 and May 2018 at a tertiary academic medical center. A paired sample t-test and a penalized logic regression model were constructed to identify relationships between breast laterality and outcomes.
RESULTS
A total of 1117 patients with unilateral breast cancer who underwent bilateral mastectomy and immediate breast implant reconstruction were identified. Rates of capsular contracture and infection were significantly greater in the diseased breast, while rates of revision were significantly greater in the contralateral prophylactic breast. There were no statistically significant differences between breasts in rates of explant, skin flap necrosis or hematoma. When adjusted for confounding variables, a higher infection rate was observed in the diseased breast.
CONCLUSION
This study detected significant differences in postoperative complication rates between the diseased and prophylactic breasts following bilateral mastectomy and immediate breast implant reconstruction. Postoperative complications occurred more frequently in the diseased breast compared with low rates of complications in the contralateral prophylactic breast. This information is helpful for preoperative decision making, as surgeons and patients carefully weigh the additional risks of contralateral prophylactic procedure.
Topics: Adult; Breast Implantation; Breast Neoplasms; Combined Modality Therapy; Female; Humans; Mammaplasty; Middle Aged; Neoplasm Grading; Neoplasm Staging; Postoperative Complications; Prophylactic Mastectomy; Risk Assessment; Treatment Outcome
PubMed: 31605310
DOI: 10.1007/s10549-019-05460-0 -
Breast Cancer Research and Treatment Oct 2020Contralateral prophylactic mastectomy (CPM) is increasingly performed in average-risk patients despite the lack of survival benefit. In an era of heightened awareness of...
PURPOSE
Contralateral prophylactic mastectomy (CPM) is increasingly performed in average-risk patients despite the lack of survival benefit. In an era of heightened awareness of healthcare costs, we sought to determine the impact of CPM on financial toxicity in breast cancer.
METHODS
A single-institution propensity-matched analysis of female patients who underwent unilateral mastectomy (UM) with or without CPM for breast cancer over an 18-month period. Patients with a history of genetic predisposition or bilateral cancer were excluded. The validated Comprehensive Score for financial Toxicity (COST) evaluated financial toxicity among participants. Multivariable regression analysis evaluated the relationship between CPM and financial toxicity. Relevant domains of the Breast Q and SF12 instruments were examined as secondary outcomes. Sensitivity analysis was performed using propensity-weighting to examine robustness of results and increase our sample size.
RESULTS
Overall, 104 patients were identified, equally distributed across UM and CPM. CPM was not associated with financial toxicity, as evidenced by comparable COST scores (adjusted difference, 1.53 [- 3.24 to 6.29]). Minor complications were significantly lower in UM patients (UM, 8%; CPM, 31%). CPM was associated with significantly higher Breast Q psychosocial well-being score (adjusted difference, 10.58 [1.34 to 19.83]). BREAST Q surgeon satisfaction, SF12 mental and physical component scores were comparable. Similar results were noted on sensitivity analysis involving 194 patients.
CONCLUSIONS
Choice for CPM was associated with higher minor complications, but led to improved psychosocial well-being without a higher degree of patient-reported financial toxicity. Prospective studies are needed to discern the influence of CPM on the incidence and trajectory of financial toxicity.
Topics: Breast Neoplasms; Female; Humans; Mastectomy; Propensity Score; Prophylactic Mastectomy; Prospective Studies
PubMed: 32691378
DOI: 10.1007/s10549-020-05805-0 -
Annals of Surgical Oncology Dec 2023Breast oncology generates extensive literature and widespread media attention every year because of the high worldwide burden of this disease and also because of the... (Review)
Review
Breast oncology generates extensive literature and widespread media attention every year because of the high worldwide burden of this disease and also because of the rapid pace at which treatment advances have progressed. The year 2021 was no different, and this review will summarize some of the practice-changing, practice-validating, and practice-challenging publications of that year. These studies cover a broad range of topics including multidisciplinary care with gene expression profiling; breast cancer disparities; breast cancer screening; and prophylactic mastectomy surgery.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Prophylactic Mastectomy
PubMed: 37798553
DOI: 10.1245/s10434-023-14230-8 -
Journal of Breast Imaging Jan 2024Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening... (Review)
Review
Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening of patients with BRCA1 or BRCA2 pathogenic gene mutations if they have not undergone prophylactic mastectomy. It will review the current evidence-based imaging recommendations for different modalities and ages of screening initiation in screening this patient population at high risk. Special considerations in transgender BRCA1 and BRCA2 mutation carriers are also discussed.
Topics: Humans; Female; Breast Neoplasms; Mammography; Mastectomy; Mutation; Genes, BRCA2
PubMed: 38166173
DOI: 10.1093/jbi/wbad093 -
European Journal of Surgical Oncology :... Jun 2020The purpose of this article is to illuminate differences in published clinical practice guideline recommendations for breast reconstruction after prophylactic and... (Review)
Review
BACKGROUND
The purpose of this article is to illuminate differences in published clinical practice guideline recommendations for breast reconstruction after prophylactic and therapeutic mastectomy.
METHODS
Ten guidelines were identified through a systematic search of websites and databases of reputable oncology guideline developers, and key differences and gaps in recommendations were noted. Quality assessment of the guidelines was conducted by three reviewers using the AGREE II tool, focusing on breast reconstruction specific documents rather than the general breast cancer guidelines.
RESULTS
The most comprehensive guidelines were published by Alberta Health Services, Cancer Care Ontario, the American Society of Plastic Surgeons, and the Association of Breast Surgery/British Association of Plastic Reconstructive and Aesthetic Surgeons. AGREE II scores in the domains of "Scope and Purpose" and "Clarity and Presentation" were ranked relatively high for all four guidelines while "Applicability" and "Editorial Independence" were ranked relatively low. The Alberta and Ontario guidelines were the overall highest ranked guidelines across all domains.
CONCLUSION
Overall, these guidelines provide consistent recommendations on who should receive breast reconstruction education, who is a candidate for postmastectomy breast reconstruction, and the appropriate timing of reconstruction and extent of mastectomy. Future updates from all should focus on expanding to include alloplastic and autologous forms of reconstruction and should include a broad scope of relevant questions.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Practice Guidelines as Topic; Prognosis; Prophylactic Mastectomy
PubMed: 32057564
DOI: 10.1016/j.ejso.2020.01.024 -
Annals of Plastic Surgery Jun 2023Increasingly patients with unilateral breast cancer elect to undergo bilateral mastectomy with subsequent reconstruction. Studies have aimed to better identify the risks...
BACKGROUND
Increasingly patients with unilateral breast cancer elect to undergo bilateral mastectomy with subsequent reconstruction. Studies have aimed to better identify the risks associated with performing mastectomy on the noncancerous breast. Our study aims to identify differences in complications between therapeutic and prophylactic mastectomy in patients undergoing implant-based breast reconstruction.
METHODS
A retrospective analysis of implant-based breast reconstruction from 2015 to 2020 at our institution was completed. Patients with less than 6-month follow-up after final implant placement had reconstruction using autologous flaps, expander or implant rupture, metastatic disease requiring device removal, or death before completion of reconstruction were excluded. McNemar test identified differences in incidence of complications for therapeutic and prophylactic breasts.
RESULTS
After analysis of 215 patients, we observed no significant difference in incidence of infection, ischemia, or hematoma between the therapeutic and prophylactic sides. Therapeutic mastectomies had higher odds of seroma formation ( P = 0.03; odds ratio, 3.500; 95% confidence interval, 1.099-14.603). Radiation treatment status was analyzed for patients with seroma; 14% of patients unilateral seroma of the therapeutic side underwent radiation (2 of 14), compared with 25% patients with unilateral seroma of the prophylactic side (1 of 4).
CONCLUSIONS
For patients undergoing mastectomy with implant-based reconstruction, the therapeutic mastectomy side has an increased risk of seroma formation.
Topics: Humans; Female; Mastectomy; Retrospective Studies; Breast Neoplasms; Seroma; Postoperative Complications; Mammaplasty; Breast Implants; Prophylactic Mastectomy; Treatment Outcome
PubMed: 36811478
DOI: 10.1097/SAP.0000000000003460 -
The British Journal of Surgery Jun 2023Nipple-sparing mastectomy is associated with a higher risk of mastectomy skin-flap necrosis than conventional skin-sparing mastectomy. There are limited prospective data...
BACKGROUND
Nipple-sparing mastectomy is associated with a higher risk of mastectomy skin-flap necrosis than conventional skin-sparing mastectomy. There are limited prospective data examining modifiable intraoperative factors that contribute to skin-flap necrosis after nipple-sparing mastectomy.
METHODS
Data on consecutive patients undergoing nipple-sparing mastectomy between April 2018 and December 2020 were recorded prospectively. Relevant intraoperative variables were documented by both breast and plastic surgeons at the time of surgery. The presence and extent of nipple and/or skin-flap necrosis was documented at the first postoperative visit. Necrosis treatment and outcome was documented at 8-10 weeks after surgery. The association of clinical and intraoperative variables with nipple and skin-flap necrosis was analysed, and significant variables were included in a multivariable logistic regression analysis with backward selection.
RESULTS
Some 299 patients underwent 515 nipple-sparing mastectomies (54.8 per cent (282 of 515) prophylactic, 45.2 per cent therapeutic). Overall, 23.3 per cent of breasts (120 of 515) developed nipple or skin-flap necrosis; 45.8 per cent of these (55 of 120) had nipple necrosis only. Among 120 breasts with necrosis, 22.5 per cent had superficial, 60.8 per cent had partial, and 16.7 per cent had full-thickness necrosis. On multivariable logistic regression analysis, significant modifiable intraoperative predictors of necrosis included sacrificing the second intercostal perforator (P = 0.006), greater tissue expander fill volume (P < 0.001), and non-lateral inframammary fold incision placement (P = 0.003).
CONCLUSION
Modifiable intraoperative factors that may decrease the likelihood of necrosis after nipple-sparing mastectomy include incision placement in the lateral inframammary fold, preserving the second intercostal perforating vessel, and minimizing tissue expander fill volume.
Topics: Humans; Female; Mastectomy; Nipples; Mammaplasty; Prospective Studies; Breast Neoplasms; Mastectomy, Subcutaneous; Postoperative Complications; Necrosis; Retrospective Studies
PubMed: 37178195
DOI: 10.1093/bjs/znad107 -
Breast (Edinburgh, Scotland) Mar 2022The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of...
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013-08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
Topics: Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Mastectomy; Mastectomy, Segmental; Neoplasm Staging; Sentinel Lymph Node Biopsy
PubMed: 34949533
DOI: 10.1016/j.breast.2021.11.018 -
Breast Cancer Research and Treatment Dec 2021Our study aimed to explore temporal trends and survival benefit of contralateral prophylactic mastectomy (CPM) in male breast cancer (MBC).
PURPOSE
Our study aimed to explore temporal trends and survival benefit of contralateral prophylactic mastectomy (CPM) in male breast cancer (MBC).
METHODS
Men with stage I-III unilateral breast cancer between 1998 and 2016 were identified from the surveillance, epidemiology, and end results (SEER). We compared CPM rate over the study period using the Cochrane-Armitage test for trend. Logistic regression model was used to test for factors predicting CPM. Survival analysis was conducted in patients who underwent CPM or unilateral mastectomy (UM) with a first diagnosis of unilateral breast cancer. Kaplan-Meier curve and univariate and multivariable Cox proportional hazards regression analyses were performed to compare overall survival (OS) and breast cancer-specific survival (BCSS) between CPM and UM groups. Propensity score matching was adopted to balance baseline characteristics.
RESULTS
5118 MBC cases were included in the present study, with 4.1% (n = 209) patients underwent CPM. The proportion of men undergoing CPM increased from 1.7 in 1998 to 6.3% in 2016 (P < 0.0001). Young age, recent years of diagnosis, higher tumor grade and lower T stage were significantly associated with CPM. A cohort of 3566 patients were enrolled in survival analysis with a median follow-up of 65 months. CPM was associated with better OS (HR 0.58, 95% CI 0.37-0.89, P = 0.022) rather than BCSS (HR 0.57, 95% CI 0.29-1.11, P = 0.153) compared with UM. In propensity score-matched model, CPM was not an independent prognostic factor for OS (HR 0.83, 95% CI 0.46-1.52, P = 0.553) and BCSS (HR 0.98, 95% CI 0.39-2.47, P = 0.970).
CONCLUSION
Our study revealed a dramatic increase in CPM utilization among MBC, especially in young patients. However, CPM provides no survival benefit for MBC compared with UM, indicating the decision of CPM should be fully discussed.
Topics: Breast Neoplasms; Breast Neoplasms, Male; Humans; Male; Mastectomy; Prophylactic Mastectomy; SEER Program; Unilateral Breast Neoplasms; United States
PubMed: 34554371
DOI: 10.1007/s10549-021-06397-z -
Cancer Causes & Control : CCC Dec 2023Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been...
PURPOSE
Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.
METHODS
Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.
RESULTS
Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).
CONCLUSION
The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.
Topics: Female; Humans; Mastectomy; Breast Neoplasms; Unilateral Breast Neoplasms; Prophylactic Mastectomy; Probability
PubMed: 37095280
DOI: 10.1007/s10552-023-01689-9