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Plastic and Reconstructive Surgery May 2019Decisions made to undergo contralateral prophylactic mastectomy, in women at low risk for bilateral disease, are often attributed to a lack of knowledge. This study...
BACKGROUND
Decisions made to undergo contralateral prophylactic mastectomy, in women at low risk for bilateral disease, are often attributed to a lack of knowledge. This study examines the role knowledge plays in determining surgical treatment for unilateral breast cancer made by laywomen and surgeons for themselves or loved ones.
METHODS
The study cohort had three groups: (1) laywomen in the general population, (2) breast surgeons, and (3) plastic surgeons. Laywomen were recruited using Amazon Mechanical Turk Crowd Sourcing. Breast and plastic surgeons from nine states were sent electronic surveys. Demographic and contralateral prophylactic mastectomy-specific data on decisions and knowledge were collected and analyzed.
RESULTS
Surveys from 1333 laywomen, 198 plastic surgeons, and 142 breast surgeons were analyzed. A significantly greater proportion of laywomen in the general population favored contralateral prophylactic mastectomy (67 percent) relative to plastic (50 percent) and breast surgeons (26 percent) (p < 0.0001). Breast surgeons who chose contralateral prophylactic mastectomy were younger (p = 0.044) and female (0.012). On assessment of knowledge, 78 percent of laywomen had a low level of breast cancer knowledge. Laywomen with higher levels of breast cancer knowledge had lower odds of choosing contralateral prophylactic mastectomy (OR, 0.37; 95 percent CI, 0.28 to 0.49).
CONCLUSIONS
Fewer women are likely to make decisions in favor of contralateral prophylactic mastectomy with better breast cancer-specific education. A knowledge gap likely explains the lower rates with which surgeons choose contralateral prophylactic mastectomy for themselves or loved ones; however, some surgeons who were predominantly young and female favor contralateral prophylactic mastectomy. Improving patient education on surgical options for breast cancer treatment is critical, with well-informed decisions as the goal.
Topics: Adult; Age Factors; Breast; Cohort Studies; Decision Making; Female; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Patient Education as Topic; Prophylactic Mastectomy; Risk Assessment; Sex Factors; Surgeons; Surveys and Questionnaires; Unilateral Breast Neoplasms; Young Adult
PubMed: 31033815
DOI: 10.1097/PRS.0000000000005523 -
Annales de Chirurgie Plastique Et... Jun 2018The objective of our study was to evaluate the risk of cancer after prophylactic nipple-sparing mastectomy (PNSM). (Review)
Review
INTRODUCTION
The objective of our study was to evaluate the risk of cancer after prophylactic nipple-sparing mastectomy (PNSM).
MATERIAL AND METHODS
The PubMed database was consulted using the following key-words: "nipple-sparing mastectomy", "prophylactic", "locoregional recurrence", "oncological risk". Articles published between January 1995 and December 2016 were searched.
RESULTS
Out of the 270 articles found, 19 were included. Overall, 15 studies were retrospective, 2 prospective, 2 prospective and retrospective and 3 were multicentric. All told, they involved 3890 patients corresponding to 6786 mastectomies, among which the total number of prophylactic nipple-sparing mastectomies was 3716. Average age of the patients was 44.4years and average follow-up was 38.4months (8-168months); 29.4% of them had a BRCA 1 or 2 mutation; 85 and 15% underwent prosthetic and autologous reconstructions, respectively. Average cancer rates exterior to and within the nipple areolar complex (NAC) were 0.2 and 0.004%, respectively. The overall average rate of histological pre-malignant lesions in the nipple areolar complex was 1.5%. The overall complication rate was 20.5%, and necrosis rates of the nipple areolar complex and the skin were 8.1 and 7.1%, respectively.
CONCLUSION
In prophylactic breast surgery, conservation of the nipple areolar complex does not seem to increase the risk of cancer development. However, short follow-up time and the different methodologies applied in the different studies presently preclude generalization of the technique.
Topics: Breast Neoplasms; Female; Humans; Nipples; Organ Sparing Treatments; Prophylactic Mastectomy; Risk Assessment
PubMed: 29030030
DOI: 10.1016/j.anplas.2017.09.005 -
The Breast Journal 2022Patients with unilateral breast cancer carrying pathogenic variants in have the option to undergo contralateral prophylactic mastectomy (CPM). However, differences in...
BACKGROUND
Patients with unilateral breast cancer carrying pathogenic variants in have the option to undergo contralateral prophylactic mastectomy (CPM). However, differences in CPM use and survival outcomes following CPM are poorly understood in this high-risk population, in part due to a lack of data from contemporary clinical cohorts. The objective of this study was to evaluate post-CPM overall survival (OS) and related racial/ethnic differences in a contemporary clinical cohort.
METHODS
We retrospectively reviewed the medical records of women with a personal history of unilateral breast cancer carrying pathogenic variants in who were diagnosed between 1996 and 2012. Genetic test results, self-reported demographic characteristics, and clinical factors were abstracted from electronic medical records.
RESULTS
Of 144 BRCA-positive patients, the majority were White (79.2%, = 114). Overall, 56.1% ( = 81) of all carriers chose to undergo CPM, with no racial/ethnic difference in CPM election ( = 0.78). Of 81 patients who underwent CPM, there is strong evidence of a difference in survival between the racial/ethnic groups, with White patients having the highest OS compared to non-White patients ( = 0.001). Of the 63 patients who did not undergo CPM, there is no racial/ethnic difference in overall survival ( = 0.61). In multivariable cox regression, adjusted for demographic and clinical characteristics, OS was significantly lower among non-Whites than in Whites (HR = 0.39, = 0.04).
CONCLUSIONS
Evaluation of a contemporary clinical cohort of BRCA-positive women with unilateral breast cancer showed no racial/ethnic difference in CPM use, but there was a significant difference in post-CPM overall survival.
Topics: Humans; Female; Mastectomy; Prophylactic Mastectomy; Retrospective Studies; Unilateral Breast Neoplasms; Breast Neoplasms; BRCA1 Protein
PubMed: 36685664
DOI: 10.1155/2022/1447545 -
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 -
Rambam Maimonides Medical Journal Oct 2015Following the announcement of actress Angelina Jolie's prophylactic bilateral mastectomies and subsequent prophylactic oophorectomy, there has been a dramatic increase...
BACKGROUND
Following the announcement of actress Angelina Jolie's prophylactic bilateral mastectomies and subsequent prophylactic oophorectomy, there has been a dramatic increase in interest in BRCA testing and prophylactic surgery.
OBJECTIVE
To review current medical literature on the benefits of prophylactic mastectomy and oophorectomy among BRCA-positive women and its permissibility under Jewish law.
RESULTS
Recent literature suggests that in BRCA-positive women who undergo prophylactic oophorectomy the risk of dying of breast cancer is reduced by 90%, the risk of dying of ovarian cancer is reduced by 95%, and the risk of dying of any cause is reduced by 77%. The risk of breast cancer is further reduced by prophylactic mastectomy. Prophylactic oophorectomy and prophylactic mastectomy pose several challenges within Jewish law that call into question the permissibility of surgery, including mutilation of a healthy organ, termination of fertility, self-wounding, and castration. A growing number of Jewish legal scholars have found grounds to permit prophylactic surgery among BRCA carriers, with some even obligating prophylactic mastectomy and oophorectomy.
CONCLUSION
Current data suggest a significant reduction in mortality from prophylactic mastectomy and oophorectomy in BRCA carriers. While mutilation of healthy organs is intrinsically forbidden in Jewish law, the ability to preserve human life may contravene and even mandate prophylactic surgery.
PubMed: 26886774
DOI: 10.5041/RMMJ.10222 -
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 Apr 2018Prognostic and treatment uncertainty make ductal carcinoma in situ (DCIS) complex to manage. The purpose of this study was to describe research that evaluated DCIS... (Review)
Review
PURPOSE
Prognostic and treatment uncertainty make ductal carcinoma in situ (DCIS) complex to manage. The purpose of this study was to describe research that evaluated DCIS communication experiences, needs and interventions among DCIS patients or physicians.
METHODS
MEDLINE, EMBASE, CINAHL and The Cochrane Library were searched from inception to February 2017. English language studies that evaluated patient or physician DCIS needs, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings.
RESULTS
A total of 51 studies published from 1997 to 2016 were eligible for review, with a peak of 8 articles in year 2010. Women with DCIS lacked knowledge about the condition and its prognosis, although care partners were more informed, desired more information and experienced decisional conflict. Many chose mastectomy or prophylactic mastectomy, often based on physician's recommendation. Following treatment, women had anxiety and depression, often at levels similar to those with invasive breast cancer. Disparities were identified by education level, socioeconomic status, ethnicity and literacy. Physicians said that they had difficulty explaining DCIS and many referred to DCIS as cancer. Despite the challenges reported by patients and physicians, only two studies developed interventions designed to improve patient-physician discussion and decision-making.
CONCLUSIONS
As most women with DCIS undergo extensive treatment, and many experience treatment-related complications, the paucity of research on PE to improve and support informed decision-making for DCIS is profound. Research is needed to improve patient and provider discussions and decision-making for DCIS management.
Topics: Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Clinical Decision-Making; Female; Health Knowledge, Attitudes, Practice; Humans; Patients; Physicians
PubMed: 29273956
DOI: 10.1007/s10549-017-4613-x -
Preventive Medicine Jul 1995Women with a first-degree relative with breast cancer are at increased risk of developing this disease. The optimal medical management of these women is unclear, with...
BACKGROUND
Women with a first-degree relative with breast cancer are at increased risk of developing this disease. The optimal medical management of these women is unclear, with options including close breast cancer screening, bilateral prophylactic mastectomy, or participation in chemoprevention trials. Among women who undergo prophylactic bilateral mastectomy, very little is known about satisfaction with this surgery. Also, we know very little about variables related to prophylactic mastectomy decision making.
METHODS
Participants were women at increased risk of breast cancer due to family history. These women were categorized by self-report as not interested in prophylactic mastectomy (n = 58), interested but deciding against surgery (n = 92), or subsequently having a bilateral prophylactic mastectomy (n = 14). Information on screening practices, risk perception, level of depression, and cancer-related worry was collected. Women completing prophylactic mastectomy reported on their satisfaction with the surgery and breast reconstruction.
RESULTS
Women selecting surgery reported more breast cancer worry. The group expressing no interest in surgery reported fewer biopsies and lower risk estimates. Women completing surgery were satisfied with their decision, although satisfaction with reconstruction was mixed.
CONCLUSION
Factors influencing surgical decision making may include breast-cancer-related worry, biopsy history, and subjective breast cancer risk.
Topics: Adult; Analysis of Variance; Biopsy; Breast Neoplasms; Chi-Square Distribution; Decision Making; Disease Susceptibility; Family Health; Female; Humans; Life Change Events; Mammaplasty; Mastectomy; Middle Aged; Patient Satisfaction; Patient Selection; Stress, Psychological
PubMed: 7479633
DOI: 10.1006/pmed.1995.1066 -
Annals of Surgical Oncology Oct 2016
Topics: Breast; Consensus; Female; Genes, BRCA1; Genes, BRCA2; Heterozygote; Humans; Organ Sparing Treatments; Patient Preference; Postoperative Complications; Prophylactic Mastectomy; Risk Assessment; Societies, Medical; Unilateral Breast Neoplasms; United States
PubMed: 27469117
DOI: 10.1245/s10434-016-5443-5 -
Frontiers in Oncology 2018Despite limited oncologic benefit, contralateral prophylactic mastectomy (CPM) rates have increased in the United States over the past 15 years. CPM is often...
Despite limited oncologic benefit, contralateral prophylactic mastectomy (CPM) rates have increased in the United States over the past 15 years. CPM is often accompanied by breast reconstruction, thereby requiring an interdisciplinary approach between breast and plastic surgeons. Despite this, little is known about plastic surgeons' (PS) perspectives of CPM. The purpose of this study was to assess PS practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process. An electronic survey was sent to 2,642 members of the American Society of Plastic Surgeons (ASPS). Questions assessed demographics, practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process. ASPS response rate was 12.5% ( = 329). Most responders worked in private practice (69%), were male (81%) and had been in practice for ≥15 years (60%). The median number of CPM reconstructions performed per month was 2-4. Fifty-five percent of PS reported routine attendance at a breast multidisciplinary conference. Responders reported CPM discussion was most likely to be initiated by the patient (51%) followed by the breast surgeon (38%), and plastic surgeon (7.3%). According to PS, the most common reason patients choose CPM is a perceived increased contralateral cancer risk (86%). Most plastic surgeons (63%) assessed the benefits of CPM as worth the risk of additional surgery and the majority (53%) estimated the complication rate at 2X the risk of unilateral surgery. The majority (61%) of PS estimated risk of contralateral cancer in an average risk patient between <2 and 5% over 10 years, which is consistent with data reported from the current literature. Most plastic surgeons (87%) reported that there was no evidence or limited evidence for breast cancer specific survival benefit with CPM. A minority of PS (18.5%) reported discomfort with a patient's choice for CPM. Of those surgeons reporting discomfort, the most common reasons for their reservations were a concern with the risk/benefit ratio of CPM and with lack of patient understanding of expected outcomes. Common reasons for PS comfort with CPM were a respect for autonomy and non-oncologic benefits of CPM. To our knowledge, this is the first survey reporting PS perspectives on CPM. According to PS, CPM dialogue appears to be patient driven and dominated by a perceived increased risk of contralateral cancer. Few PS reported discomfort with CPM. While many PS acknowledge both the limited oncologic benefit of CPM and the increased risk of complications, the majority have the opinion that the benefits of CPM are worth the additional risk. This apparent contradiction may be due to an appreciation of the non-oncologic benefits CPM and a desire to respect patients' choices for treatment.
PubMed: 30687634
DOI: 10.3389/fonc.2018.00647