Bilateral Mastectomy in Women With Unilateral Breast Cancer: A Review.

Importance: Rates of bilateral mastectomy continue to increase in average-risk women with unilateral in situ and invasive breast cancer. Contralateral prophylactic mastectomy rates increased from 5% to 12% of all operations for breast cancer in the US from 2004 to 2012. Among women having mastectomy, rates of contralateral prophylactic mastectomy have increased from less than 2% in 1998 to 30% in 2012. Observations: The increased use of breast magnetic resonance imaging and genetic testing has marginally increased the number of candidates for bilateral mastectomy. Most bilateral mastectomies are performed on women who are at no special risk for contralateral cancer. The true risk of contralateral breast cancer is not associated with the decision for contralateral prophylactic mastectomy; rather, the clinical factors associated with the probability of distant recurrence are associated with bilateral mastectomy. Several changes in society and health care delivery appear to act concurrently and synergistically. First, the anxiety engendered by a fear of cancer recurrence is focused on the contralateral cancer because this is most easily conceptualized and provides a ready target that can be acted upon. Second, the modern woman with breast cancer is supported by the surgeon and the social community of breast cancer survivors. Surgeons want to respect patient autonomy, despite guidelines discouraging bilateral mastectomy, and most women have their expenses covered by a third-party payer. Satisfaction with the results is high, but the association with improved psychosocial well-being remains to be fully understood. Conclusions and Relevance: Reducing the use of medically unnecessary contralateral prophylactic mastectomy in women with nonhereditary, unilateral breast cancer requires a social change that addresses patient-, physician-, cultural-, and systems-level enabling factors. Such a transformation begins with educating clinicians and patients. The concerns of women who want preventive contralateral mastectomy must be explored, and women need to be informed of the anticipated benefits (or lack thereof) and risks. Areas requiring further study are considered.

New Cardiac Abnormalities After Radiotherapy in Breast Cancer Patients Treated With Trastuzumab.

PURPOSE: To evaluate cardiac imaging abnormalities after modern radiotherapy and trastuzumab in breast cancer patients. PATIENTS AND METHODS: All patients treated with trastuzumab and radiotherapy for breast cancer between 2006 and 2014 with available cardiac imaging (echocardiogram or multigated acquisition scan) were retrospectively analyzed. Cardiac abnormalities included myocardial abnormalities (atrial or ventricular dilation, hypertrophy, hypokinesis, and impaired relaxation), decreased ejection fraction > 10%, and valvular abnormalities (thickening or stenosis of the valve leaflets). Breast laterality (left vs. right) and heart radiation dose volume parameters were analyzed for association with cardiac imaging abnormalities. RESULTS: A total of 110 patients with 57 left- and 53 right-sided breast cancers were evaluated. Overall, 37 patients (33.6%) developed a new cardiac abnormality. Left-sided radiotherapy was associated with an increase in new cardiac abnormalities (relative risk [RR] = 2.51; 95% confidence interval [CI], 1.34-4.67; P = .002). Both myocardial and valvular abnormalities were associated with left-sided radiotherapy (myocardial: RR = 2.21; 95% CI, 1.06-4.60; P = .029; valvular: RR = 3.30; 95% CI, 0.98-10.9; P = .044). There was no significant difference in decreased ejection fraction between left- and right-sided radiotherapy (9.6% vs. 2.1%; P = .207). A mean heart dose > 2 Gy as well as volume of the heart receiving 20 Gy (V20), V30, and V40 correlated with cardiac abnormalities (mean heart dose > 2 Gy: RR = 2.00; P = .040). CONCLUSION: New cardiac abnormalities, including myocardial and valvular dysfunction, are common after trastuzumab and radiotherapy. The incidence of new abnormalities correlates with tumor laterality and cardiac radiation dose exposure. Long-term follow-up is needed to understand the clinical significance of these early imaging abnormalities.

The use of contralateral prophylactic mastectomy among elderly patients in the United States.

PURPOSE: Previous studies have reported increased rates of contralateral prophylactic mastectomy (CPM) in the United States among women with unilateral breast cancer. These trends have primarily focused on younger breast cancer patients. Given the growing aging population in the United States, we sought to determine whether CPM use is also increasing in elderly patients. METHODS: This population-based study identified patients in the surveillance epidemiology and end results (SEER) data. We determined the rate of CPM as a proportion of all surgically treated patients and as a proportion of all mastectomies. We compared the unadjusted CPM rates over the study period using the Cochrane-Armitage test for trend. We used a logistic regression model to test for the factors associated with CPM utilization. RESULTS: We identified 261,281 patients ≥ 65 years who underwent surgical treatment for breast cancer. For all patients treated with surgery for invasive breast cancer, the use of CPM increased from 1 in 2004 to 3% in 2014 (200% increase). Among mastectomy patients, the use of CPM increased from 3 in 2004 to 7% in 2014 (133% increase). Young age, non-Hispanic white race, lobular histology, higher grade, increased stage, negative lymph node status, and recent year of diagnosis were significantly associated with increased CPM rates. CONCLUSIONS: For elderly patients the use of CPM has continued to increase in the United States. These observations warrant concern in light of increasing evidence that CPM does not improve oncological outcomes and is associated with increased morbidity in older patients.

Comparison of heart dose in early-stage left-sided breast cancers treated with intraoperative radiation therapy or whole-breast irradiation with deep inspiratory breath hold.

PURPOSE: To compare heart dose between patients treated with lumpectomy and either intraoperative radiation therapy (IORT) with CT-guided high-dose-rate brachytherapy (precision breast IORT [PB-IORT]) or whole-breast irradiation with deep inspiratory breath hold (WBI-DIBH) for early-stage left-sided breast cancers. METHODS AND MATERIALS: We retrospectively identified the 17 patients with left-sided breast cancers treated with PB-IORT on a phase I clinical trial and 17 patients with left-sided tumors who had undergone lumpectomy and adjuvant WBI-DIBH. Dosimetric data were obtained. T-testing was performed and biologically effective doses (BEDs) were calculated using an α/ß ratio of 2 Gy. RESULTS: Mean heart dose was significantly lower with WBI-DIBH compared with PB-IORT (0.61 vs. 0.87 Gy, p = 0.006). Mean heart BED was lower with WBI-DIBH (0.62 vs. 1.3 Gy2, p = 0.0001). Nominal maximum heart dose was higher with WBI-DIBH (11.37 vs. 4.81 Gy, p = 0.004). Maximum heart dose BED was similar between WBI-DIBH and IORT, 16.63 vs. 19.36 Gy (p = 0.64), respectively. No difference was found in mean left anterior descending artery dose: 2.18 Gy with WBI-DIBH and 1.89 Gy with IORT (p = 0.446). The maximum left anterior descending doses were 9.63 Gy and 3.62 Gy with WBI-DIBH and IORT, respectively (p = 0.016). Distance from the heart to the lumpectomy cavity was inversely associated with heart dose for PB-IORT, but not for WBI-IORT. CONCLUSIONS: Heart doses were low in both groups. Expected increase in cardiac risk at these doses is minimal. It is unlikely that there will be a clinically significant difference in cardiac toxicity in patients treated with WBI-DIBH or PB-IORT. Further research is needed to evaluate the actual clinical impact of the observed cardiac doses delivered with these modalities.

Incidence and tumour characteristics of bilateral and unilateral interval breast cancers at screening mammography.

BACKGROUND: Detected by screening mammography, bilateral breast cancer has a different pathological profile compared to unilateral breast cancer. We investigated the incidence of bilateral interval breast cancers and compared their characteristics with those of unilateral interval breast cancers. METHODS: We included all 468,720 screening mammograms of women who underwent biennial screening mammography in the South of the Netherlands between January 2005 and January 2015. We collected breast imaging reports, biopsy results and surgical reports of all referred women and of all women who presented with interval breast cancer. The tumour with the highest tumour stage (index cancer) was used for comparison with unilateral interval cancers. RESULTS: A total of 753 interval cancers were detected, of which 24 (3.2%) were bilateral. Among the invasive interval cancers, bilateral cancers more frequently showed a lobular histology than unilateral cancers (37.5% (9/24) vs. 16.1% (111/691), P = .01). There is a trend towards a larger proportion of bilateral than unilateral interval cancers graded 1 (45.8% (11/24) vs. 27.8% (192/691), P = .08). There were no other statistically significant differences in tumour characteristics. Also, the proportion of interval cancers showing significant mammographic abnormalities at the latest screen was comparable for unilateral and bilateral interval cancers (23.0% vs. 25.0%, P = .9). DISCUSSION: Bilateral interval cancers comprise a small proportion of all interval cancers. Except of a higher proportion of invasive lobular cancers and a more favourable histological grade of invasive cancers, tumour characteristics are comparable for bilateral and unilateral interval breast cancers.

Intensity modulated radiotherapy with fixed collimator jaws for locoregional left-sided breast cancer irradiation.

The purpose of this study is to evaluate the intensity modulated radiotherapy (IMRT) with the fixed collimator jaws technique (FJT) for the left breast and regional lymph node. The targeted breast tissue and the lymph nodes, and the normal tissues were contoured for 16 left-sided breast cancer patients previously treated with radiotherapy after lumpectomy. For each patient, treatment plans using different planning techniques, i.e., volumetric modulated arc therapy (VMAT), tangential IMRT (tangential-IMRT), and IMRT with FJT (FJT-IMRT) were developed for dosimetric comparisons. A dose of 50Gy was prescribed to the planning target volume. The dose-volume histograms were generated, and the paired t-test was used to analyze the dose differences. FJT-IMRT had similar mean heart volume receiving 30Gy (V30 Gy) with tangential-IMRT (1.5% and 1.6%, p = 0.41), but inferior to the VMAT (0.8%, p < 0.001). In the average heart mean dose comparison, FJT-IMRT had the lowest value, and it was 0.6Gy lower than that for the VMAT plans (p < 0.01). A significant dose increase in the contralateral breast and lung was observed in VMAT plans. Compared with tangential-IMRT and VMAT plans, FJT-IMRT reduced the mean dose of thyroid, humeral head and cervical esophageal by 47.6% (p < 0.01) and 45.7% (p < 0.01), 74.3% (p =< 0.01) and 73% (p =< 0.01), and 26.7% (p =< 0.01) and 29.2% (p =< 0.01). In conclusion, compared with tangential-IMRT and VMAT, FJT-IMRT plan has the lowest thyroid, humeral head and cervical esophageal mean dose and it can be a reasonable treatment option for a certain subgroup of patients, such as young left-breast cancer patients and/or patients with previous thyroid disease.

Women's preferences for contralateral prophylactic mastectomy: An investigation using protection motivation theory.

OBJECTIVE: Most women diagnosed with unilateral breast cancer without BRCA1 or BRCA2 mutations are at low risk of contralateral breast cancer. Contralateral Prophylactic Mastectomy (CPM) decreases the relative risk of contralateral breast cancer, but may not increase life expectancy; yet international uptake is increasing. This study applied protection motivation theory (PMT) to determine factors associated with women's intentions to undergo CPM. METHODS: Three hundred eighty-eight women previously diagnosed with unilateral breast cancer and of negative or unknown BRCA1 or BRCA2 status were recruited from an advocacy group's research database. Participants completed measures of PMT constructs based on a common hypothetical CPM decision-making scenario. RESULTS: PMT constructs explained 16% of variance in intentions to undergo CPM. Response efficacy (CPM's advantages) and response costs (CPM's disadvantages) were unique individual predictors of intentions. CONCLUSION: Decision-making appears driven by considerations of the psychological, cosmetic and emotional advantages and disadvantages of CPM. Overestimations of threat to life from contralateral breast cancer and survival benefit from CPM also appear influential factors. PRACTICE IMPLICATIONS: Patients require balanced and medically accurate information regarding the pros and cons of CPM, survival rates, and recurrence risks to ensure realistic and informed decision-making.

Cuidado de enfermería en paciente postoperada de mastectomía: estudio de caso / Nursing care in postoperative mastectomy patient: a case study

Introducción: El cáncer de mama es una de las neoplasias más frecuentes en mujeres a nivel mundial y causan más muertes cada año. El diagnóstico oportuno es muy importante ya que es de relevancia en la elección y eficacia del tratamiento, teniendo mayor éxito cuando se detecta temprano. La mejor estrategia para la detección temprana es a través de la prevención primaria mediante información, orientación y educación a la población femenina acerca de los factores de riesgo y la promoción de conductas favorables a la salud. El objetivo del estudio fue identificar dominios y clases afectadas en paciente postoperada de mastectomía. Materiales y Métodos: Estudio de caso en paciente femenina de 47 años de edad diagnosticada con cáncer de mama izquierda, realizándole mastectomía radical izquierda en una institución de salud del sector privado de Tampico, Tamaulipas, México. Se aplicó el proceso enfermero, realizando la valoración de enfermería con la Taxonomía II de Diagnósticos de enfermería, se describen los dominios y clases afectadas en el periodo posoperatorio, implementándose el plan de cuidados de enfermería con las interrelaciones diagnósticos, intervenciones y resultados. Resultados: La paciente evolucionó favorablemente, egresando al tercer día de la intervención quirúrgica, se proporcionó educación para sus cuidados en el domicilio. Discusión y Conclusiones: Al finalizar la investigación del caso, se observó la importancia de llevar a cabo el plan de cuidados de enfermería con las respectivas interrelaciones para brindar atención de calidad.

Introduction: Breast cancer is one of the most common cancers in women worldwide and causes more deaths each year. Early diagnosis is very important because it is relevant in the choice and treatment efficacy, with greater success when caught early. The best strategy for early detection is through primary prevention through information, guidance and education to the female population about risk factors and promoting positive health behaviors. The aim of the study was to identify domains and affected classes in a postoperative mastectomy patient. Materials and Methods: A case study in female patients of 47 years of age diagnosed with left breast cancer, performing left radical mastectomy in a private health institution in Tampico, Tamaulipas, Mexico. The nursing process was applied, making the nursing assessment with Taxonomy II Nursing Diagnoses, domains and affected classes in the postoperative period are described, implementing the nursing care plan with interrelationships, diagnoses, interventions and outcomes. Results: The patient improved, egressing the third day after surgery, education was provided for care at home. Discussion and Conclusions: After investigating the case, the importance of carrying out the plan of nursing care with the respective relationships to provide quality care was observed.