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Personalized Medicine Nov 2023To describe the indications and outcomes of mutation carriers undergoing nipple-sparing mastectomy (NSM). In this retrospective study, 76 mutation carriers with no...
To describe the indications and outcomes of mutation carriers undergoing nipple-sparing mastectomy (NSM). In this retrospective study, 76 mutation carriers with no cancer who opted to undergo risk reduction NSM or diagnosed with breast cancer (BC) who opted to undergo therapeutic NSM were included. Indications for NSM: cancer treatment (n = 33), bilateral risk reduction (n = 39) and contralateral prophylactic NSM (n = 4). In a mean follow-up of 45 months (median: 30 months), one patient (2.5%) undergoing risk-reducing NSM developed a new BC. One (3%) local, one (3%) ipsilateral axillary and one (3%) distant recurrence were observed in BC patients. No partial or total nipple necrosis occurred. NSM is safe for reducing the risk of BC development in mutation carriers and for treating cancer.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Retrospective Studies; Nipples; Mutation; BRCA1 Protein; BRCA2 Protein
PubMed: 37909344
DOI: 10.2217/pme-2023-0084 -
Current Oncology (Toronto, Ont.) Oct 2023Pathogenic variants (PVs) in and increase the lifetime risks of breast and ovarian cancer. Guidelines recommend breast screening (magnetic resonance imaging (MRI) and...
Specialty Care and Counselling about Hereditary Cancer Risk Improves Adherence to Cancer Screening and Prevention in Newfoundland and Labrador Patients with Pathogenic Variants: A Population-Based Retrospective Cohort Study.
Pathogenic variants (PVs) in and increase the lifetime risks of breast and ovarian cancer. Guidelines recommend breast screening (magnetic resonance imaging (MRI) and mammogram) or risk-reducing mastectomy (RRM) and salpingo-oophorectomy (RRSO). We sought to (1) characterize the population of PV carriers in Newfoundland and Labrador (NL), (2) evaluate risk-reducing interventions, and (3) identify factors influencing screening and prevention adherence. We conducted a retrospective study from a population-based provincial cohort of PV carriers. The eligibility criteria for risk-reducing interventions were defined for each case and patients were categorized based on their level of adherence with recommendations. Chi-squared and regression analyses were used to determine which factors influenced uptake and level of adherence. A total of 276 PV carriers were identified; 156 living NL biological females composed the study population. Unaffected females were younger at testing than those with a cancer diagnosis (44.4 years versus 51.7 years; = 0.002). Categorized by eligibility, 61.0%, 61.6%, 39.0%, and 75.7% of patients underwent MRI, mammogram, RRM, and RRSO, respectively. Individuals with breast cancer were more likely to have RRM (64.7% versus 35.3%; < 0.001), and those who attended a specialty hereditary cancer clinic were more likely to be adherent to recommendations (73.2% versus 13.4%; < 0.001) and to undergo RRSO (84.1% versus 15.9%; < 0.001). Nearly 40% of the female PV carriers were not receiving breast surveillance according to evidence-based recommendations. Cancer risk reduction and uptake of breast imaging and prophylactic surgeries are significantly higher in patients who receive dedicated specialty care. Organized hereditary cancer prevention programs will be a valuable component of Canadian healthcare systems and have the potential to reduce the burden of disease countrywide.
Topics: Humans; Female; Breast Neoplasms; BRCA1 Protein; Mastectomy; Retrospective Studies; BRCA2 Protein; Early Detection of Cancer; Genetic Predisposition to Disease; Newfoundland and Labrador; Canada; Counseling
PubMed: 37887578
DOI: 10.3390/curroncol30100678 -
World Journal of Surgical Oncology Oct 2023Minimal-accessed (robotic and endoscopic) breast cancer surgery is increasingly performed due to better cosmetic results and acceptable oncological outcomes. This study...
BACKGROUND
Minimal-accessed (robotic and endoscopic) breast cancer surgery is increasingly performed due to better cosmetic results and acceptable oncological outcomes. This study aims to demonstrate the clinical safety and patient-reported cosmetic satisfaction of single-port three-dimensional endoscopic-assisted breast surgery (S-P 3D EABS), which is our new endoscopic surgical innovation, in both malignant and benign breast conditions.
METHODS
Patients who underwent S-P 3D EABS from 1 August 2018 to 31 July 2022 in a single institution were enrolled. Clinical outcomes of this procedure were retrospectively reviewed, and the patient-reported cosmetic satisfaction was evaluated by a questionnaire and reported herein.
RESULTS
During the study period, 145 patients underwent 164 procedures of S-P 3D EABS. One hundred fifty (91.5%) procedures were endoscopic-assisted nipple-sparing mastectomy (S-P 3D E-NSM; 117 therapeutic procedures for breast cancer, 13 prophylactic mastectomies, 20 procedures for gynecomastia). Fourteen (8.5%) procedures of endoscopic-assisted breast-conserving surgery (S-P 3D E-BCS) were performed (12 S-P 3D E-BCS, 2 S-P 3D E-BCS with 3D videoscope-assisted partial breast reconstruction, which was 1 case of latissimus dorsi flap and 1 case of omental flap). The mean operative time was 245 ± 110 min in S-P 3D E-NSM and 260 ± 142 min in S-P 3D E-BCS. The mean intraoperative blood loss was 49.7 ± 46.9 ml in S-P 3D E-NSM and 32.8 ± 17.5 ml in S-P 3D E-BCS. Subnipple biopsy showed positive malignancy in 3 (2.6%) S-P 3D E-NSM patients. None of the S-P 3D E-BCS patients found margin involvement; however, 3 (2.6%) reported margin involvement in S-P 3D E-NSM patients. Thirty-two complications were found (24.6%): 7 (5.3%) transient nipple-areolar complex (NAC) ischemia, 7 (5.3%) partial NAC necrosis, 1 (0.7%) total NAC necrosis, and 1 (0.7%) implant loss. During the mean follow-up time of 34 months, there were 2 (1.5%) patients with locoregional recurrence, 9 (6.9%) distant metastasis, and 2 (1.5%) mortality. 78.6% (77/98) of patients answering the cosmetic-evaluated questionnaire reported good and excellent overall satisfaction.
CONCLUSIONS
S-P 3D EABS is a novel surgical innovation, which is able to perform safely in either malignant or benign breast conditions and offer promising cosmetic results.
Topics: Humans; Breast Neoplasms; Gynecomastia; Mammaplasty; Mastectomy; Necrosis; Neoplasm Recurrence, Local; Nipples; Patient Reported Outcome Measures; Patient Satisfaction; Retrospective Studies; Female
PubMed: 37880770
DOI: 10.1186/s12957-023-03191-7 -
Annals of Surgical Oncology Jan 2024Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been...
BACKGROUND
Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction.
PATIENTS AND METHODS
We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort.
RESULTS
We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011).
CONCLUSION
Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.
Topics: Humans; Aged; Female; Mastectomy; Retrospective Studies; Frailty; Breast Neoplasms; Frail Elderly; Mammaplasty; Postoperative Complications; Treatment Outcome; Patient Reported Outcome Measures
PubMed: 37864119
DOI: 10.1245/s10434-023-14412-4 -
Surgery Mar 2024In July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral...
BACKGROUND
In July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer. We incorporated these into practice with structured patient counseling and aimed to assess the effect of this initiative on contralateral prophylactic mastectomy rates.
METHODS
We evaluated female patients with unilateral breast cancer undergoing mastectomy at our institution from January 2011 to November 2022. Variables associated with contralateral prophylactic mastectomy and trends over time were analyzed using the Wilcoxon rank sum test or χ analysis as appropriate.
RESULTS
Among 3,208 patients, (median age 54 years) 1,366 (43%) had a unilateral mastectomy, and 1,842 (57%) also had a concomitant contralateral prophylactic mastectomy. Across all patients, contralateral prophylactic mastectomy rates significantly decreased post-implementation from 2017 to 2019 (55%) vs 2015 to 2016 (62%) (P = .01) but increased from 2020 to 2022 (61%). Immediate breast reconstruction rate was 70% overall (81% with contralateral prophylactic mastectomy and 56% without contralateral prophylactic mastectomy, P < .001). Younger age, White race, mutation status, and earlier stage were also associated with contralateral prophylactic mastectomy. Genetic testing increased from 27% pre-guideline to 74% 2020 to 2022, as did the proportion of patients with a pathogenic variant (4% pre-guideline vs 11% from 2020-2022, P < .001), of whom 91% had a contralateral prophylactic mastectomy. Among tested patients without a pathogenic variant and patients not tested, contralateral prophylactic mastectomy rates declined from 78% to 67% and 48% to 38% pre -and post-guidelines, respectively, P < .001.
CONCLUSION
Implementation of specific patient counseling was effective in decreasing contralateral prophylactic mastectomy rates. While recognizing that patient choice plays a significant role in the decision for contralateral prophylactic mastectomy, further educational efforts are warranted to affect contralateral prophylactic mastectomy rates, particularly in the setting of negative genetic testing.
Topics: Female; Humans; Middle Aged; Mastectomy; Prophylactic Mastectomy; Breast Neoplasms; Unilateral Breast Neoplasms; Mammaplasty
PubMed: 37863697
DOI: 10.1016/j.surg.2023.09.015 -
Plastic and Reconstructive Surgery.... Oct 2023Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have...
Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) ( < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction.
PubMed: 37850203
DOI: 10.1097/GOX.0000000000005353 -
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 -
Gland Surgery Sep 2023Autologous breast reconstruction has consistently demonstrated excellent patient satisfaction, ideal aesthetic results, and a low risk of complications. With the... (Review)
Review
Autologous breast reconstruction has consistently demonstrated excellent patient satisfaction, ideal aesthetic results, and a low risk of complications. With the increasing incidence of breast cancer diagnoses and higher reconstruction rates, surgeons encounter a broader spectrum of patients. Obese patients undergoing breast reconstruction are more likely to experience a surgical complication. While free tissue transfer carries a higher donor site complication rate, implant-based reconstruction carries a higher loss of reconstruction in this population. Additionally, autologous reconstruction consistently demonstrates better patient-reported outcomes. Oncoplastic reconstruction is an oncologically safe alternative to free tissue transfer and implant reconstruction which reduces the risk of complications and the risk of delaying adjuvant therapy. Particularly in obese patients for whom radiation is indicated based on tumor size or nodal involvement, oncoplastic reconstruction is maximally beneficial. The Goldilocks mastectomy is yet another alternative to free tissue transfer or implant reconstruction which carries an acceptable risk profile, especially when augmentation with tissue expander or implant is delayed and performed at a second stage. In patients with breast ptosis undergoing skin-sparing mastectomy, vertical skin reduction allows an acceptable aesthetic result while minimizing the risk for mastectomy flap necrosis (MFN), especially in comparison to Wise pattern skin reduction. If a nipple-sparing mastectomy (NSM) is to be performed in the setting of breast ptosis, a nipple delay or a pre-mastectomy reduction/mastopexy is the safest and most conservative approach, but can alter the timeline for primary cancer resection and therefore is predominantly performed in patients with a genetic predisposition or those undergoing a prophylactic mastectomy. Patients with obesity, breast ptosis, advanced age, active smoking history, prior radiation therapy, or abdominal procedures can carry an increased risk of complications and present a challenge to plastic surgeons. We review the most recent literature published regarding reconstruction in these patient groups and seek to provide practical information to help inform clinical decision-making and operative execution.
PubMed: 37842527
DOI: 10.21037/gs-22-710 -
American Journal of Surgery Jan 2024Risk-reducing mastectomy (RRM) is the most effective breast cancer risk-reduction strategy in BRCA1/2 mutation carriers. We examined factors associated with RRM and its...
BACKGROUND
Risk-reducing mastectomy (RRM) is the most effective breast cancer risk-reduction strategy in BRCA1/2 mutation carriers. We examined factors associated with RRM and its relationship with overall survival (OS).
METHODS
Patients aged 18-80y at diagnosis of their BRCA1/2 mutation were selected from our institutional database and stratified by RRM receipt. Differences were tested; unadjusted OS was estimated.
RESULTS
Of the 306 patients, median age was 43y; median follow-up was 41.6mo. Patients undergoing RRM were more often married with a history of pregnancy (both p ≤ 0.05). Of female patients, 23.1% underwent RRM. Two patients had malignancy detected at RRM, and one developed breast cancer after RRM. Higher unadjusted OS was observed with RRM (p = 0.02).
CONCLUSIONS
Our analyses suggest that family-structure may play a role in a patient's decision to undergo RRM. We also demonstrated RRM is likely associated with improved survival, potentially underscoring the importance of this option for BRCA1/2 mutation carriers.
Topics: Humans; Female; Adult; Mastectomy; Breast Neoplasms; BRCA1 Protein; Genes, BRCA2; BRCA2 Protein; Heterozygote; Mutation
PubMed: 37827871
DOI: 10.1016/j.amjsurg.2023.10.011 -
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