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Translational Behavioral Medicine May 2020Rates of contralateral prophylactic mastectomy (CPM) have risen substantially, yet little is known about how and to what extent CPM is discussed within surgical oncology...
Rates of contralateral prophylactic mastectomy (CPM) have risen substantially, yet little is known about how and to what extent CPM is discussed within surgical oncology visits at the time of treatment decision-making. We examined CPM discussions in naturally occurring interactions between sporadic breast cancer patients and their surgical oncology providers. Women with early-stage unilateral disease were recruited before their first surgical visit and completed brief questionnaires to determine study eligibility and interest in treatment options. After their visits, enrolled patients and their providers completed questionnaires assessing discussion of and interest in CPM. Audio-recorded visits from 36 unique patients were randomly selected, transcribed, and analyzed. A CPM discussion was present in 28 transcripts. Approximately half of CPM discussions were initiated by the patient or the oncology provider. The topic of CPM was most frequently introduced while reviewing available treatment options. Patients were most interested in pursuing CPM to reduce the risk of future breast cancer. Providers most frequently responded by offering information (e.g., about risk of contralateral disease). A high level of agreement was found among patient, provider, and observer ratings of whether or not CPM was discussed. CPM discussions were consistently present within our sample. Results can be used to build providers' skills and bring provider-patient communication more in line with best practices and recommendations from leading professional medical societies.
Topics: Breast Neoplasms; Decision Making; Female; Humans; Mastectomy; Prophylactic Mastectomy; Surgical Oncology; Surveys and Questionnaires
PubMed: 30561744
DOI: 10.1093/tbm/iby098 -
American Journal of Surgery Mar 2022Contralateral prophylactic mastectomy rates have substantially increased. The study aimed to examine contralateral prophylactic mastectomy (CPM) at the time of...
BACKGROUND
Contralateral prophylactic mastectomy rates have substantially increased. The study aimed to examine contralateral prophylactic mastectomy (CPM) at the time of ipsilateral breast tumor recurrence (IBTR) and evaluate factors contributing to CPM decision making process.
METHOD
Patients who developed IBTR after BCS from 2011 to 2019 were reviewed. Patient and tumor characteristics, genetic testing and reconstruction details were analyzed.
RESULTS
Ninety-six patients had IBTR after BCS and were treated with mastectomy, with 30% electing for a CPM. Patients who underwent CPM were younger, had higher BMI and less comorbidities. A genetic mutation was identified in 19% of patients who underwent testing at the time of IBTR. Tumor characteristics and performing surgeon were not predictors for CPM, however, patients were more likely to undergo CPM if they received reconstruction of the ipsilateral breast with IBTR.
CONCLUSION
This study shows that age, BMI, genetic testing and breast reconstruction are factors contributing to CPM decision at the time of IBTR.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Neoplasm Recurrence, Local; Prophylactic Mastectomy
PubMed: 34924172
DOI: 10.1016/j.amjsurg.2021.12.009 -
JAMA Surgery Apr 2021Through the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation...
IMPORTANCE
Through the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation.
OBJECTIVE
To identify variation and determinants of persistent use of low-value breast cancer surgical care.
DESIGN, SETTING, AND PARTICIPANTS
Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation.
MAIN OUTCOMES AND MEASURES
Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission.
RESULTS
The total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another.
CONCLUSIONS AND RELEVANCE
Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and performance.
Topics: Adult; Aged; Breast Neoplasms; Decision Making; Female; Humans; Mastectomy; Middle Aged; Practice Patterns, Physicians'; Registries; Reproducibility of Results; Retrospective Studies; United States
PubMed: 33533894
DOI: 10.1001/jamasurg.2020.6942 -
Journal of Breast Cancer Apr 2021Nipple-sparing mastectomy (NSM) includes various techniques, including conventional or endoscopic mastectomies. Since the introduction of robot-assisted NSM (RANSM) in...
PURPOSE
Nipple-sparing mastectomy (NSM) includes various techniques, including conventional or endoscopic mastectomies. Since the introduction of robot-assisted NSM (RANSM) in 2015, 2 main methods have been used: gasless and gas-inflated techniques. The aim of this study was to compare clinicopathologic characteristics, surgical outcomes, and postoperative complications between patients treated with gasless RANSM and those treated with gas-inflated RANSM.
METHODS
We conducted a retrospective study of women who underwent gasless or gas-inflated RANSM with immediate breast reconstruction between November 2016 and May 2019. The indications for RANSM were early breast cancer, interstitial mastopathy, or 1/2 mutation carriers. Clinicopathologic characteristics, surgical outcomes, and postoperative complications were analyzed. The severity of complications was graded using the Clavien-Dindo system.
RESULTS
A total of 58 RANSM procedures were performed in 46 women: 15 cases of gasless RANSM and 43 cases of gas-inflated RANSM. The proportion of node-negative disease was higher in the gas-inflated group (97.1%) than in the gasless group (69.2%, = 0.016). Adjuvant radiotherapy was administered in 30.6% of the cases in the gasless group and only 5% of the cases in the gas-inflated group. Other clinicopathological factors were not significantly different between the groups. Regarding surgical outcomes, the initial incision was 1 cm longer in the gasless group (5.17 ± 0.88 cm) than that in the gas-inflated group (4.20 ± 1.05 cm; = 0.002). The final incision was also longer in the gasless group (5.17 ± 0.88 cm) than that in the gas-inflated group (4.57 ± 1.07 cm; = 0.040). Operation time, complication rate, and complication grade were not significantly different between the 2 groups.
CONCLUSION
In this study, there were no significant differences in surgical outcomes or postoperative complications between gasless and gas-inflated RANSM, except for a longer incision with the gasless technique. Both techniques are reasonable options for RANSM followed by immediate reconstruction.
PubMed: 33913274
DOI: 10.4048/jbc.2021.24.e20 -
Cancers Jan 2020The uptake of contralateral prophylactic mastectomy is rising with increasing trends that are possibly highest in the USA. Whilst its role is generally accepted in... (Review)
Review
The uptake of contralateral prophylactic mastectomy is rising with increasing trends that are possibly highest in the USA. Whilst its role is generally accepted in carriers of recognized high-risk predisposition genes such as and when the affected individual is premenopausal, controversy surrounds the benefit in less understood risk-profile clinical scenarios. This comprehensive review explores the current evidence underpinning the role of contralateral prophylactic mastectomy and its impact on contralateral breast cancer risk and survival in three distinct at-risk groups affected by unilateral breast cancer: known genetic carriers, those with strong familial risk but no demonstrable genetic mutation and women who are of young age at presentation. The review supports the role of contralateral prophylactic mastectomy in "high risk" groups where the evidence suggests a reduction in contralateral breast cancer risk. However, this benefit is less evident in women who are just young at presentation or those who have strong family history but no demonstrable genetic mutation. A multidisciplinary and personalized approach to support individuals in a shared-decision making process is recommended.
PubMed: 31935898
DOI: 10.3390/cancers12010140 -
Breast Care (Basel, Switzerland) Apr 2021Female carriers of a or germline mutation face a high lifetime risk to develop breast and ovarian cancer. Risk-reducing surgery, such as prophylactic bilateral... (Review)
Review
BACKGROUND
Female carriers of a or germline mutation face a high lifetime risk to develop breast and ovarian cancer. Risk-reducing surgery, such as prophylactic bilateral mastectomy and prophylactic bilateral salpingo-oophorectomy, are proven strategies to prevent breast and ovarian cancer. These procedures are, however, associated with considerable side effects, and the uptake of these highly effective interventions is therefore low in many countries. This highlights the need for alternative and noninvasive strategies for risk reduction in mutation carriers.
SUMMARY
While endocrine treatments with tamoxifen and aromatase inhibitors (AI) have been shown to be effective in secondary prevention, their benefit in primary prevention has never been prospectively evaluated. Moreover, their side effect profile makes them inappropriate candidates for chemoprevention in healthy premenopausal women. Recently, denosumab, a well-tolerated osteoprotective drug, has been shown to have an antitumoral effect on RANK+, -deficient luminal progenitor cells in vitro, and has been demonstrated to abrogate tumors in -deficient mouse models.
KEY MESSAGE
The prospectively randomized, double-blind BRCA-P trial is currently investigating the preventative effect of denosumab in healthy germline mutation carriers.
PubMed: 34012368
DOI: 10.1159/000507503 -
The Breast Journal Apr 2020The aim of this study was to determine the incidence of occult breast carcinoma and significant breast disease in clinically and radiologically unremarkable breast...
The aim of this study was to determine the incidence of occult breast carcinoma and significant breast disease in clinically and radiologically unremarkable breast reduction specimens and prophylactic mastectomies. A retrospective search using specimen type codes was performed in the computerized histopathology archive from April 2007 to April 2016. The pathology results of 505 patients were analyzed (782 specimens). A total of 267 patients underwent simple reduction mammoplasties (10 unilateral), 20 had bilateral prophylactic mastectomies and 218 undertook contralateral symmetrizing or prophylactic mastectomy surgery following a history of breast cancer. Overall, normal (unremarkable) breast tissue was found in 42.6% of patients (n = 215), benign tissue (nonproliferative/proliferative disease without atypia) in 51.1% (n = 258), significant disease (LCIS/proliferative disease with atypia) in 5.5% (n = 28), and malignant disease (invasive/ductal carcinoma in situ) in 0.8% (n = 4). The incidence of significant breast pathology was statistically higher (P value < .0001) in prophylactic mastectomies (12.4%) compared to reduction mammoplasties (2.3%). There was however no significant increase in the incidence of malignancy between prophylactic mastectomies (1.2%) and reduction mammoplasties (0.6%). Even though the clear majority of resected tissue in reduction mammoplasties and prophylactic mastectomies is benign, our findings support the continued need for histological examination of these specimens for occult carcinoma and precursor lesions.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Prophylactic Mastectomy; Retrospective Studies
PubMed: 31448509
DOI: 10.1111/tbj.13512 -
Breast Cancer Research and Treatment Jul 2021Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the...
PURPOSE
Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns.
METHODS
Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression.
RESULTS
22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86).
CONCLUSION
There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.
Topics: Adult; Breast Neoplasms; Female; Humans; Mastectomy; Prophylactic Mastectomy; Registries; Rural Population
PubMed: 33582888
DOI: 10.1007/s10549-021-06105-x -
Plastic and Reconstructive Surgery Nov 2020There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the...
BACKGROUND
There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the index breast cancer may delay adjuvant therapy. The study objective was to examine the effect of simultaneous contralateral prophylactic mastectomy with immediate breast reconstruction on the complication rate and adjuvant therapy timing.
METHODS
A retrospective study was conducted of consecutive patients who underwent contralateral prophylactic mastectomy with immediate breast reconstruction and received adjuvant therapy over a 6-year period. Demographic, treatment, and outcomes data were collected, and relationships between multiple variables and outcomes were evaluated.
RESULTS
Of 241 patients (482 breasts) included, 186 (372 breasts) underwent simultaneous index breast mastectomy and contralateral prophylactic mastectomy with immediate breast reconstruction followed by adjuvant therapy (immediate group), and 55 (110 breasts) underwent index mastectomy, then adjuvant therapy, followed by delayed contralateral prophylactic mastectomy with immediate breast reconstruction (delayed group). Demographics were similar, although breast cancer stage (p < 0.001), tumor category (p = 0.0072), and nodal category (p < 0.001) were significantly higher in the delayed group. In the immediate group, complications before adjuvant therapy occurred in 31 patients (16.7 percent), and in six patients (3.2 percent) complications occurred only in the contralateral prophylactic mastectomy breast; delay to adjuvant therapy occurred in 11 patients (5.9 percent), in four (2.2 percent) of whom the contralateral prophylactic mastectomy breast was responsible for the delay.
CONCLUSIONS
Contralateral prophylactic mastectomy with immediate breast reconstruction can be performed safely at the time of the index mastectomy in carefully selected patients. These findings will engage patients seeking contralateral prophylactic mastectomy in shared decision-making regarding optimal timing with respect to the risks and benefits.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, III.
Topics: Adult; Breast Neoplasms; Chemotherapy, Adjuvant; Female; Humans; Mammaplasty; Mastectomy; Middle Aged; Postoperative Complications; Prophylactic Mastectomy; Radiotherapy, Adjuvant; Retrospective Studies; Time Factors; Time-to-Treatment
PubMed: 33136936
DOI: 10.1097/PRS.0000000000007237 -
Life (Basel, Switzerland) Jan 2024(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender... (Review)
Review
(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.
PubMed: 38255753
DOI: 10.3390/life14010138