Breast Cancer Screening and Prophylactic Mastectomy for High-Risk Women in Romania.

Breast cancer remains a significant contributor to morbidity and mortality within oncology. Risk factors, encompassing genetic and environmental influences, significantly contribute to its prevalence. While germline mutations, notably within the BRCA genes, are commonly associated with heightened breast cancer risk, a spectrum of other variants exists among affected individuals. Diagnosis relies on imaging techniques, biopsies, biomarkers, and genetic testing, facilitating personalised risk assessment through specific scoring systems. Breast cancer screening programs employing mammography and other imaging modalities play a crucial role in early detection and management, leading to improved outcomes for affected individuals. Regular screening enables the identification of suspicious lesions or abnormalities at earlier stages, facilitating timely intervention and potentially reducing mortality rates associated with breast cancer. Genetic mutations guide screening protocols, prophylactic interventions, treatment modalities, and patient prognosis. Prophylactic measures encompass a range of interventions, including chemoprevention, hormonal inhibition, oophorectomy, and mastectomy. Despite their efficacy in mitigating breast cancer incidence, these interventions carry potential side effects and psychological implications, necessitating comprehensive counselling tailored to individual cases.

Construction and Validation of a Nomogram Predicting the Overall Survival Benefit of Unilateral Breast Cancer Patients Undergoing Contralateral Prophylactic Mastectomy.

BACKGROUND: Currently, research on the prognostic factors of unilateral breast cancer (UBC) patients receiving contralateral prophylactic mastectomy (CPM) is limited. This study aimed to construct a new nomogram to predict these patients' overall survival (OS). METHODS: In this retrospective study, 88,477 patients who underwent CPM or unilateral mastectomy (UM) were selected from the Surveillance, Epidemiology, and End Results database. Kaplan-Meier curves and Cox regression analyses were used to determine the difference in the impact of the 2 surgical methods on the prognosis. Multivariate Cox analysis was used to determine the best prognostic variable and construct a nomogram. The concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to evaluate the discrimination capability and clinical effectiveness of the nomogram. RESULTS: The prognosis of patients receiving CPM and UM was significantly different. The DCA curves indicated that the nomogram could provide more excellent clinical net benefits for these patients. The NRI and IDI of the nomogram demonstrated that its performance was better than that of the classical tumor-node-metastasis (TNM) staging system. CONCLUSION: This study developed and validated a practical nomogram to predict the OS of UBC patients undergoing CPM, which provided a beneficial tool for clinical decision-making management.

The impact of prophylactic mastectomy on sexual well-being: a systematic review.

INTRODUCTION: Considering the increasing women's awareness of health promotion and disease prevention programs, mutation carriers are inevitably asked to face important decisions concerning the possibility of undergoing prophylactic mastectomy. Risk-reducing mastectomy (RRM) has become increasingly more common, although it has a significant impact on women's quality of life and sexual well-being. OBJECTIVES: The systematic review aims to evaluate the impact of RRM on the sexuality of women with breast cancer. METHODS: According to Cochrane Collaboration guidelines and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, the study quantified the effects of frontline work on the mental health of healthcare workers. This review followed the PRISMA guidelines. Three databases were systematically searched from inception to December 2022. The expression ("sexuality" OR "sexual" OR "sex") AND ("prophylactic mastectomy" OR "risk-reducing mastectomy") was searched in PubMed, Ovid Medline, and Embase. Twenty-two articles published in English until 2022 were selected. RESULTS: Two studies investigated sexual experience after risk-reducing surgeries as a single outcome, while other studies analyzed the relationship between sexuality and psychosocial outcomes, risk perception, and satisfaction. In all of the included studies, significant findings in sexual dysfunction were found. The most reported problems were related to sexual satisfaction and attractiveness, body image, and loss of femininity. Last, women reported changes in the relationship with their partners. CONCLUSION: RRM has a major impact on body image that affects sexual functioning and quality of life. These implications must be considered during treatment selection.

Patient-reported outcomes in bilateral prophylactic mastectomy with breast reconstruction: A narrative review.

In women at high risk of developing breast cancer, bilateral prophylactic mastectomy (BPM) 1 significantly reduces the risk; simultaneously, breast reconstruction preserves body integrity. Given the complex and personal nature of such surgical procedures, patient assessment of satisfaction and health-related quality of life (HRQoL) 2 is essential in evaluation of surgical outcomes. With this review, we aim to organize the current knowledge on patient-reported outcomes (PROs) 3 in bilateral prophylactic surgery. Literature search was conducted using the databases Google Scholar, PubMed, and Web of Science to address the following questions, which can help clinicians and women undergoing the procedures navigate their healthcare decision-making process: How does BPM with reconstruction influence cancer-related distress? How does the surgery impact patient satisfaction and HRQoL? How do preoperative PROs differ from postoperative outcomes? Does the type of BPM and the type of reconstruction impact patient satisfaction and HRQoL? Furthermore, we summarize available patient-reported outcome measures (PROMs) 4 that can be administered to women undergoing BPM with reconstruction. In addition, we discuss possible future directions for PRO research in prophylactic breast surgery.

Complications Associated with Contralateral Prophylactic Mastectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: No meta-analysis has examined whether contralateral prophylactic mastectomy increases complication risk for unilateral breast cancer patients undergoing unilateral mastectomy. METHODS: Fifteen studies on complications of unilateral mastectomy plus contralateral prophylactic mastectomy met inclusion criteria. Meta-analyses compared complications of (1) diseased versus contralateral breasts in unilateral plus contralateral prophylactic mastectomy patients and (2) patients undergoing unilateral plus contralateral prophylactic mastectomy versus unilateral alone when grouped by reconstructive method. RESULTS: For all unilateral plus contralateral prophylactic mastectomy patients, the diseased breast was significantly more prone to complications versus the contralateral breast (relative risk, 1.24; p = 0.03). In studies that stratified by reconstructive method, the complication risk was significantly higher for unilateral plus contralateral prophylactic mastectomy versus unilateral mastectomy alone for patients with no reconstruction (relative risk, 2.03; p = 0.0003), prosthetic-based reconstruction (relative risk,1.42; p = 0.003), and autologous reconstruction (relative risk, 1.32; p = 0.005). The only prospective trial showed similar results, including for more severe complications. Smaller retrospective studies without stratification by reconstructive method showed similar complications for unilateral plus contralateral prophylactic mastectomy versus unilateral mastectomy alone (relative risk, 1.06; p = 0.70). These groups had similar incidences of complication-related delay in adjuvant therapy, as demonstrated by one study. CONCLUSIONS: After unilateral plus contralateral prophylactic mastectomy, diseased breasts are at higher risk for complications. Stronger evidence supports higher complication risk for unilateral plus contralateral prophylactic mastectomy than unilateral alone. More work is needed to determine the effect of complications on timing of adjuvant therapy.

Analysis of a Trend Reversal in US Lumpectomy Rates From 2005 Through 2017 Using 3 Nationwide Data Sets.

Importance: Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM). Objective: To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets. Design and Setting: Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM. Results: A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period. Conclusions: This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.

How Contralateral Prophylactic Mastectomy Does the Body, or Why Epistemology Alone Cannot Explain this Controversial Breast Cancer Treatment.

Since the late 1990s, the use of contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer has been on the rise. Over the past two decades, dozens of studies have been conducted in order to understand this trend, which has puzzled and frustrated physicians who find it at odds with efforts to curb the surgical overtreatment of breast cancer, as well as with evidence-based medicine, which has established that the procedure has little oncologic benefit for most patients. Based on the work of Annemarie Mol and John Law, this paper argues that these efforts to understand increased CPM use are limited by the "epistemology problem" in medicine, or, in other words, the tendency to view healthcare controversies and decision making exclusively through the lenses of objective and subjective forms of knowledge. Drawing on public discourse about rationales for choosing CPM, we argue that this surgical trend cannot adequately be understood in terms of what doctors and patients know about breast cancer risk and how CPM affects that risk. In addition, it must be recognized as the outcome of how specific practices of screening, detection, and treatment do or enact the bodies of patients, producing tensions in their lives that cannot be remedied with better or better communicated information. Recognizing the embodied realities of these enactments and their effects on patient decision making, we maintain, is essential for physicians who want to avoid the paternalism that haunts breast cancer treatment in the US.

Utility and Outcomes of Preoperative Screening Breast MRI for Planned Bilateral Prophylactic Mastectomy in High-Risk Patients.

BACKGROUND. There is a paucity of data and consensus guidelines on the utility of preoperative MRI for planned bilateral prophylactic mastectomy. OBJECTIVE. The purpose of this study was to evaluate the utility of breast MRI performed in high-risk patients for the indication of planned bilateral prophylactic mastectomy, with attention given to the diagnostic performance for breast cancer detection. A secondary aim was to assess the potential impact of breast MRI findings on the decision to perform sentinel lymph node biopsy at the time of prophylactic mastectomy. METHODS. A retrospective database review identified MRI examinations performed at an academic medical center from August 2003 to January 2020 for the indication of planned bilateral prophylactic mastectomy. Patient demographics, imaging findings, operative details, and pathology were recorded. BI-RADS category 1 and 2 assessments were considered negative examinations, and BI-RADS category 3, 4, and 5 assessments were considered positive examinations. Descriptive statistics and performance metrics were calculated. RESULTS. The final cohort included 53 patients (mean age, 45 years). Most (35/53; 66.0%) studies were baseline examinations. Of the 53 patients, 31 (58.5%) had negative MRI examinations and 22 (41.5%) had positive MRI examinations. MRI detected two malignancies (one invasive lobular carcinoma and one high-grade ductal carcinoma in situ), both of which were assessed as BI-RADS category 4. The patient with invasive lobular cancer underwent sentinel lymph node biopsy at the time of mastectomy, which showed metastasis. Breast MRI had sensitivity of 100.0% and specificity of 60.8% for overall breast cancer detection and sensitivity of 100.0% and specificity of 59.6% for invasive cancer detection. CONCLUSION. Preoperative MRI for planned bilateral prophylactic mastectomy detected all cancers, indicating a potential role for MRI in impacting surgical decision making. CLINICAL IMPACT. Given the high NPV for cancer, our results suggest that lymph node biopsy may be safely avoided in patients with a negative MRI examination. This is clinically relevant because sentinel nodes cannot be identified after mastectomy.

[Prophylactic mastectomy and occult cancer: a ten-year experience at a cancer center]. / Chirurgie de réduction de risque mammaire et découverte fortuite de cancer : dix ans d'expérience dans un centre de lutte contre le cancer.

INTRODUCTION: Women identified as high-risk for breast cancer may choose between close follow-up and radical mastectomy. Prophylactic mastectomy, as any other surgery, is associated with benefits and harms. The aim of this study was to assess the morbidity associated with prophylactic mastectomy and to evaluate the prevalence of occult cancers. METHODS: All patients who underwent unilateral or bilateral prophylactic mastectomy between 2007 and 2017 in our institution were eligible for inclusion in this retrospective study. Medical history, type of surgery, occurrence of complication or reoperation and pathological reports were examined in medical charts. RESULTS: 79 women underwent prophylactic mastectomy over the studied period of which 58.2% were contralateral after breast cancer. A genetic mutation was present in 86.1% of cases. Postoperative complications occurred in 43.0% of cases. An additional surgery for medical or esthetic purpose was needed in 72.1% of cases. Occult cancer was found in 11.4% of the pathological reports. Triple negative invasive ductal carcinoma was discovered in two cases (2.5%). DISCUSSION: Prophylactic mastectomy is the only effective preventive action against breast cancer. Women must be clearly informed of possible complications, high reoperation rate and potential pathological findings. Identifying women most at risk for breast cancer would help to better target those who will benefit most from surgery.

Understanding Stakeholder Preference for Contralateral Prophylactic Mastectomy: A Conjoint Analysis.

BACKGROUND: Despite increasing numbers of women with unilateral breast cancer undergoing CPM, quantitative evidence of all stakeholder preferences regarding CPM is lacking, particularly for healthy volunteers. Conjoint analysis, a marketing tool, can be used to quantify tradeoffs surrounding CPM. STUDY DESIGN: The objective of this study was to quantify preferences for aspects of contralateral prophylactic mastectomy (CPM) decision-making process among key stakeholders. Healthy volunteers, women with cancer (WwCa), surgical oncologists, and plastic surgeons were surveyed with the same conjoint simulation exercise. Respondents chose between either single (SM) or double (DM) mastectomy under varying recurrence and complication rates, surveillance, and symmetry conditions. Hierarchical Bayesian models calculated partworth utilities and importance scores. RESULTS: Overall, 1,244 respondents participated. The top 3 important factors for all stakeholders were surgical complication rates after DM, type of surgery (SM vs DM) independent of other variables, and 10-year future contralateral cancer risk after SM. HV and surgeons placed greatest importance on high rates of surgical complications after DM. WwCa preferred DM, regardless of complication risk or low rates of a 10-year future cancer episode after SM. Surgical oncologists strongly preferred SM and were more accepting of future cancer risk of 3% or 10% than other stakeholders. Symmetry and need for surveillance were least important factors for all stakeholders. CONCLUSIONS: The threshold of acceptability for future cancer episodes and risk tolerance for complications varies by stakeholder, with a profound influence upon WwCA. Current findings suggest room for improved provider and patient alignment through behavioral techniques, such as framing, meanwhile highlighting changes in risk perception after a breast cancer diagnosis.

Contralateral prophylactic mastectomy: A narrative review of the evidence and acceptability.

The uptake of contralateral prophylactic mastectomy (CPM) has increased steadily over the last twenty years in women of all age groups and breast cancer stages. Since contralateral breast cancer is relatively rare and the breast cancer guidelines only recommend CPM in a small subset of patients with breast cancer, the drivers of this trend are unknown. This review aims to evaluate the evidence for and acceptability of CPM, data on patient rationales for choosing CPM, and some of the factors that might impact patient preferences. Based on the evidence, future recommendations will be provided. First, data on contralateral breast cancer risk and CPM rates and trends are addressed. After that, the evidence is structured around four main patient rationales for CPM formulated as questions that patients might ask their surgeon: Will CPM reduce mortality risk? Will CPM reduce the risk of contralateral breast cancer? Can I avoid future screening with CPM? Will I have better breast symmetry after CPM? Also, three different guidelines regarding CPM will be reviewed. Studies indicate a large gap between patient preferences for radical risk reduction with CPM and the current approaches recommended by important guidelines. We suggest a strategy including shared decision-making to enhance surgeons' communication with patients about contralateral breast cancer and treatment options, to empower patients in order to optimize the use of CPM incorporating accurate risk assessment and individual patient preferences.

Detection of breast cancer precursor lesions by autofluorescence ductoscopy.

PURPOSE: Autofluorescence is an image enhancement technique used for the detection of cancer precursor lesions in pulmonary and gastrointestinal endoscopy. This study evaluated the feasibility of addition of autofluorescence to ductoscopy for the detection of intraductal breast cancer precursor lesions. METHODS: An autofluorescence imaging system, producing real-time computed images combining fluorescence intensities, was coupled to a conventional white light ductoscopy system. Prior to surgery, ductoscopy with white light and autofluorescence was evaluated under general anaesthesia in women scheduled for therapeutic or prophylactic mastectomy. Endoscopic findings in both modes were compared, marked and correlated with histology of the surgical specimen. RESULTS: Four breast cancer patients and five high-risk women, with a median age of 47 years (range 23-62) were included. In autofluorescence mode, two intraductal lesions were seen in two breast cancer patients, which had an increase in the red-to-green fluorescence intensity compared with the surrounding tissue. One lesion had initially been missed by white light ductoscopy but was clearly visible in subsequent autofluorescence mode. One endoscopic finding was classified as suspicious by white light, but was negative in autofluorescence mode and showed normal histology. CONCLUSIONS: This study demonstrates for the first time the in vivo feasibility of autofluorescence ductoscopy to detect pathologically confirmed breast cancer precursor lesions in both breast cancer patients and high-risk women that were occult under white light.

Bilateral immediate two-stage breast reconstruction in patients with unilateral breast cancer: Outcomes analysis and risk assessment.

INTRODUCTION: Contralateral prophylactic mastectomy has the potential to decrease the occurrence of cancer and reduce psychological burden. However, it is known that complications after bilateral mastectomy are higher compared with unilateral mastectomy. Our goal was to evaluate outcomes of immediate breast reconstruction in patients undergoing bilateral mastectomy and to compare complication rates between therapeutic and prophylactic sides. PATIENTS AND METHODS: Electronic medical records of patients with unilateral breast cancer who underwent bilateral mastectomy and immediate reconstruction with expanders were reviewed. Postoperative complications were compared between therapeutic and prophylactic mastectomy sides. RESULTS: Sixty-two patients were analyzed. The overall complication rate after both stages was 23.9% on the therapeutic side and 16.5% on the prophylactic side. Infection was the most common complication on both sides. All infections on the prophylactic mastectomy side were successfully treated with intravenous (IV) antibiotics (salvage rate of 100%), whereas 35.7% of infected tissue expander/implants on the therapeutic mastectomy side were explanted despite treatment. CONCLUSION: Careful counselling of patients undergoing elective contralateral prophylactic mastectomy is essential as complications can develop in either breast after reconstruction.

Clinical outcomes of patients after nipple-sparing mastectomy and reconstruction based on the expander/implant technique.

Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a surgical-management paradigm change toward less-aggressive surgery that combines the use of breast-conserving or -reconstruction therapy as a new standard of care with a higher emphasis on cosmesis. The implementation of skin-sparing and nipple-sparing mastectomies (SSM, NSM) has been shown to be oncologically safe, and breast reconstructive surgery is being performed increasingly for patients with breast cancer. NSM and breast reconstruction can also be performed as prophylactic or risk-reduction surgery for women with BRCA gene mutations. Compared with conventional breast construction followed by total mastectomy (TM), NSM preserving the nipple-areolar complex (NAC) with breast reconstruction provides psychosocial and aesthetic benefits, thereby improving patients' cosmetic appearance and body image. Implant-based breast reconstruction (IBBR) has been used worldwide following mastectomy as a safe and cost-effective method of breast reconstruction. We review the clinical evidence about immediate (one-stage) and delayed (two-stage) IBBR after NSM. Our results suggest that the postoperative complication rate may be higher after NSM followed by IBBR than after TM or SSM followed by IBBR.

Contralateral breast cancer and tumor recurrence in BRCA1/2 carriers and non-carriers at a high risk of hereditary breast cancer after bilateral mastectomy. / Cáncer de mama contralateral y recurrencia en portadoras BRCA1/2 y no portadoras con alto riesgo de cáncer de mama hereditario tras mastectomía bilateral.

INTRODUCTION: Contralateral prophylactic mastectomy (CPM) has been reported to reduce risk of contralateral breast cancer (CBC) by at least 90%.In addition, BRCA carriers presents higher risk of ipsilateral recurrence and a second primary tumor. The aim is to evaluate risk of CBC and recurrence and to analyze predictive factors in BRCA1/2 mutation carriers and non-carriers at high-risk of hereditary breast cancer patients. METHODS: Retrospective observational study. 46 patients underwent bilateral mastectomy during 2004-2018. RESULTS: Cohort comprised 9 patients BRCA1,12 BRCA2 and 25 at high-risk without mutation. Median follow-up 79 months. 16 patients recently diagnosed and 30 previously treated by breast cancer whom underwent CPM at second time (because of later detection of BRCA mutation in 10 cases). The external lateral incision was most frequent surgical technique. In all patients immediate reconstruction was performed. In CPM pieces, 4 in situ carcinoma, 3 invasive and 1 atypical hyperplasia were found. The incidence of occult contralateral cancer was 15.2%. Recurrence was observed in 5 patients a media of 21.2 months after surgery. FSD was 83.74 months and OS 84.33 months. Regression models identified BRCA1/2 mutation and high risk without mutation as significant occult tumor predictive factors while tumor size≥2cm was predictive of recurrence. CONCLUSIONS: In our series we found a10.8% recurrence despite CPM and 7 patients (15.2%) would have developed a CBC in subsequent years.

How to manage BRCA mutation carriers?

Inherited mutations in BRCA1 and BRCA2 genes increase the risk of development of cancer in organs especially in breast and ovary. Prevention and screening in BRCA mutation carriers are of high importance. Prophylactic surgeries are possible but are still insufficiently performed because they require surgical procedures in healthy patients. Guidelines for the management of BRCA mutations carriers must absolutely be part of the standard practice of all those involved in the management of these patients to increase the impact of the implementation of these preventive measures. There is no screening recommended for ovarian cancer. A risk-reducing bilateral salpingo-oophorectomy should be performed from age 35 to 40 years for BRCA1 mutation carriers and 40 to 45 years for BRCA2 mutation carriers. A screening for breast cancer should be performed annually from 30 years old by breast MRI and mammography. A risk-reducing bilateral mastectomy is recommended with nipple sparing mastectomy and immediate breast reconstruction from 30 years and before 40 years. A multidisciplinary care must be implemented for these patients with an important psychological support.

Differences in physician opinions about controversial issues surrounding contralateral prophylactic mastectomy (CPM): A survey of physicians from accredited breast centers in the United States.

BACKGROUND: Indications and insurance coverage for contralateral prophylactic mastectomy (CPM) and CPM as a quality measure are controversial. Few studies have examined physician opinions on these issues. METHODS: A cross-sectional survey of multi-specialty physicians at the National Accreditation Program for Breast Centers from 2017-2018 examined opinions on insurance coverage for CPM, CPM as a quality measure, and indications for CPM. A multivariate logistic regression was used to assess physician and facility factors associated with likelihood to recommend CPM. RESULTS: Of 2412 physicians, 1226 responded from 382 facilities for a physician response rate of 50.8%. There were 300 (24.5%) medical oncologists, 316 (25.8%) radiation oncologists, 248 (20.2%) plastic surgeons, and 322 (26.3%) oncologic or general surgeons. Three hundred and ninety-eight (37%) physicians favor insurance coverage for all patients and 520 (46.6%) for patients at average CBC risk. Four hundred and fifty (40%) of all physicians felt physician specific rates of CPM should be a hospital quality measure. BRCA deleterious mutation carrier status was the most common indication to recommend CPM (n = 1043; 92%) and 684 (60.2%) physicians discourage CPM for average contralateral risk (CBC) patients. After adjusting for physician and facility factors, the only significant predictor of higher likelihood to recommend CPM for average CBC risk patients were plastics surgeons (OR = 8.3 (95%CI 2.4-29.1)) P = .0009). CONCLUSION: There is consensus among physicians on the most appropriate indication for CPM but opinions vary on CPM as a quality measure and insurance coverage for CPM. These findings can help guide discussions on CPM among a multidisciplinary team of physicians.