-
European Journal of Surgical Oncology :... Aug 2021Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively...
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.
Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Genes, BRCA1; Genes, BRCA2; Hereditary Breast and Ovarian Cancer Syndrome; Heterozygote; Humans; Middle Aged; Prophylactic Mastectomy; Prophylactic Surgical Procedures; Salpingo-oophorectomy; Slovenia; Time Factors; Undiagnosed Diseases
PubMed: 33812767
DOI: 10.1016/j.ejso.2021.03.248 -
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 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 -
Gland Surgery Sep 2023The use of contralateral prophylactic mastectomy (CPM) has increased over the last two decades with variations in the frequency of reconstruction. The objective of this...
BACKGROUND
The use of contralateral prophylactic mastectomy (CPM) has increased over the last two decades with variations in the frequency of reconstruction. The objective of this cohort study is to elucidate the use of CPM and reconstruction among underrepresented racial and ethnic groups and women over 65 years.
METHODS
Women over 18 years, diagnosed with stages I to III breast cancer who underwent mastectomy from 2004-2017 were identified in the National Cancer Database (NCDB) and grouped into CPM non-CPM. Multivariable analyses were used to examine the associations between CPM and reconstruction with sociodemographic and clinical factors.
RESULTS
A total of 571,649 patients were identified. Patients who underwent CPM were under 50 years (45.9%), White (88.4%) and with private insurance (73.5%). On multivariable analysis, women over 65 years [odds ratio (OR): 0.18, P<0.001], non-White (Black, OR: 0.56, P<0.001) and without private insurance (uninsured, OR: 0.50, P<0.001) had decreased odds of CPM. Women over 65 years (OR: 0.11, P<0.001), non-White (Asian/Pacific Islander, OR: 0.58, P<0.001) and without private insurance (Medicaid, OR: 0.41, P<0.001) had decreased odds of reconstruction.
CONCLUSIONS
Non-White women and women over the age of 65 years were less likely to have CPM or reconstruction than their White counterparts from 2004 to 2017. Research is needed to understand factors impacting decision-making.
PubMed: 37842536
DOI: 10.21037/gs-22-759 -
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 -
Medical Decision Making : An... Feb 2023Rates of contralateral prophylactic mastectomy (CPM)-removal of the healthy breast following breast cancer diagnosis-have increased, particularly among women for whom... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Rates of contralateral prophylactic mastectomy (CPM)-removal of the healthy breast following breast cancer diagnosis-have increased, particularly among women for whom CPM provides no survival benefit. Affective (i.e., emotional) decision making is often blamed for this increase. We studied whether greater negative breast cancer affect could motivate uptake of CPM through increased cancer risk perceptions and biased treatment evaluations.
METHODS
We randomly assigned healthy women with average breast-cancer risk ( = 1030; M = 44.14, SD = 9.23 y) to 1 of 3 affect conditions (negative v. neutral v. positive narrative manipulation) in a hypothetical online experiment in which they were asked to imagine being diagnosed with cancer in one breast. We assessed 1) treatment choice, 2) affect toward CPM, and 3) perceived risk of future breast cancer in each breast (cancer affected and healthy) following lumpectomy, single mastectomy, and CPM.
RESULTS
The manipulation caused women in the negative and neutral narrative conditions (26.9% and 26.4%, respectively) to choose CPM more compared with the positive narrative condition (19.1%). Across conditions, women's CPM affect did not differ. However, exploratory analyses addressing a possible association of affect toward cancer-related targets suggested that women in the negative narrative condition may have felt more positively toward CPM than women in the positive narrative condition. The manipulation did not have significant effects on breast cancer risk perceptions.
LIMITATIONS
The manipulation of affect had a small effect size, possibly due to the hypothetical nature of this study and/or strong a priori knowledge and attitudes about breast cancer and its treatment options.
CONCLUSION
Increased negative affect toward breast cancer increased choice of CPM over other surgical options and might have motivated more positive affective evaluations of CPM.
HIGHLIGHTS
This study used narratives to elicit different levels of negative integral affect toward breast cancer to investigate the effects of affect on breast cancer treatment choices.Increased negative affect toward breast cancer increased the choice of double mastectomy over lumpectomy and single mastectomy to treat a hypothetical, early-stage cancer.The narrative manipulation of negative affect toward breast cancer did not change the perceived risks of future cancer following any of the surgical interventions.Negative affect toward breast cancer may have biased affective evaluations of double mastectomy.
Topics: Adult; Female; Humans; Affect; Anxiety; Breast Neoplasms; Decision Making; Mastectomy; Prophylactic Mastectomy
PubMed: 36059240
DOI: 10.1177/0272989X221121134 -
International Journal of Environmental... Dec 2022A number of studies have reported breasts have high fluctuating asymmetry (FA:|Right-Left|), suggesting that they contain evolutionary and clinical information (e.g.,...
BACKGROUND
A number of studies have reported breasts have high fluctuating asymmetry (FA:|Right-Left|), suggesting that they contain evolutionary and clinical information (e.g., high FA correlates with breast cancer risk). Here we focus on breast FA in women with a wide range of breast sizes, including participants with macromastia and/or gigantomastia.
MATERIAL AND METHODS
The sample included 65 women (mean age 33.97 ± 12.1 years). Thirty were randomly selected students and/or patients who regarded their breast size as small, normal or average and who had not undergone or intended to have any breast surgery. The remainder ( = 35) were qualified for breast reduction due to macromastia and/or gigantomastia. In all participants we measured/calculated weight, height and BMI, as well as took chest photographs. Breast volumes and nipple areola complex FAs were evaluated in a specifically-designed software.
RESULTS
Breast size significantly positively correlated with breast volume FA in all women (t = 5.17, < 0.0001) and in women with macromastia/gigantomastia (t = 2.32, = 0.027). All nipple location FAs correlated positively with breast size.
CONCLUSIONS
In women with different breast sizes, breast size correlates with FA calculated from breast volume and nipple location FAs. In women with macromastia and/or gigantomastia, breasts present higher FA than "normal" breasts. This observation may give a rationale for earlier and more frequent prophylactic breast imaging in women with macromastia and/or gigantomastia.
Topics: Female; Humans; Young Adult; Adult; Middle Aged; Hypertrophy; Nipples; Mammaplasty; Mastectomy
PubMed: 36554776
DOI: 10.3390/ijerph192416895 -
The Journal of Surgical Research Jun 2021For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and...
BACKGROUND
For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse.
METHODS
Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM.
RESULTS
Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models.
CONCLUSIONS
Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Mastectomy, Segmental; Middle Aged; Prophylactic Mastectomy; Unilateral Breast Neoplasms
PubMed: 33548676
DOI: 10.1016/j.jss.2020.12.057 -
Journal of Surgical Oncology Aug 2022The COVID-19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive...
BACKGROUND
The COVID-19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive surgeries and restricting breast reconstruction options. We examined the effects of COVID-19 on oncologic breast surgery and reconstruction rates during the first year of the pandemic.
METHODS
Using the National Surgical Quality Improvement Program, we performed an observational examination of female surgical breast cancer patients from 2017 to 2020. We analyzed annual rates of lumpectomy, mastectomy (unilateral/contralateral prophylactic/bilateral prophylactic), and breast reconstruction (alloplastic/autologous) and compared 2019 and 2020 reconstruction cohorts to evaluate the effect of COVID-19.
RESULTS
From 2017 to 2020, 175 949 patients underwent lumpectomy or mastectomy with or without reconstruction. From 2019 to 2020, patient volume declined by 10.7%, unilateral mastectomy rates increased (70.5% to 71.9%, p = 0.003), and contralateral prophylactic mastectomy rates decreased. While overall reconstruction rates were unchanged, tissue expander reconstruction increased (64.0% to 68.4%, p < 0.001) and direct-to-implant and autologous reconstruction decreased. Outpatient alloplastic reconstruction increased (65.7% to 73.8%, p < 0.0001), and length of hospital stay decreased for all reconstruction patients (p < 0.0001).
CONCLUSIONS
In 2020, there was a nearly 11% decline in breast cancer surgeries, comparable mastectomy and reconstruction rates, increased use of outpatient alloplastic reconstruction, and significantly reduced in-hospital time across all reconstruction types.
Topics: Breast Implants; Breast Neoplasms; COVID-19; Female; Humans; Mammaplasty; Mastectomy; Pandemics; Retrospective Studies
PubMed: 35411946
DOI: 10.1002/jso.26889 -
Gland Surgery Jun 2021This study aimed to describe the locations of local recurrences based on the mastectomy and reconstruction type in breast cancer patients. (Review)
Review
BACKGROUND
This study aimed to describe the locations of local recurrences based on the mastectomy and reconstruction type in breast cancer patients.
METHODS
In November 2020, a systematic literature review was performed through MEDLINE/PubMed and the Cochrane Centre Register of Controlled Trials. Publications that included skin-sparing or nipple-sparing mastectomy followed by breast reconstruction and described the location of local recurrences were analyzed. Exclusion criteria included salvage or prophylactic mastectomy, unclear distinction between local and regional recurrences, rare tumor types.
RESULTS
From 19 publications, 272 local recurrences lesions were reported in a total of 4,787 patients. After autologous reconstruction (n=2,465), local recurrences were located in the skin in 45 (1.8%) patients, in the chest wall in 18 (0.7%), and in the nipple-areolar complex in 9 (0.4%). After implant reconstruction (n=1,917), local recurrences sites included the skin in 91 (4.7%) patients, chest wall in 8 (0.4%), and nipple-areolar complex in 8 (0.4%). Of the 70 lesions with reported in-breast location, 57 (81.4%) relapsed in the original tumor location.
DISCUSSION
Although meta-analysis was not conducted, present analysis demonstrated that most local recurrences after skin-sparing or nipple-sparing mastectomy occurred within the skin or subcutaneous tissues. It was found that the original tumor location was the most frequent site of relapse. Therefore, special attention should be paid to the original tumor overlying the skin while planning postmastectomy radiation therapy.
PubMed: 34268088
DOI: 10.21037/gs-21-15