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.

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.

Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM. METHODS: All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics. RESULTS: A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy. CONCLUSIONS: Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

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.

Examining Race and Patient-Reported Outcomes After Contralateral Prophylactic Mastectomy with Reconstruction.

BACKGROUND: Little is known regarding racial differences in satisfaction and quality of life (QOL) after contralateral prophylactic mastectomy (CPM). In this study, we aim to characterize associations between race, and postoperative satisfaction and well-being, utilizing the validated BREAST-Q patient-reported outcome measure. PATIENTS AND METHODS: Patients were eligible if they were diagnosed with stage 0-III unilateral breast cancer and underwent mastectomy with immediate reconstruction at our institution between 2016 and 2022. BREAST-Q surveys were administered in routine clinical care preoperatively and postoperatively to assess QOL. We assessed whether the relationship between race, and domains of satisfaction with breasts and psychosocial well-being differed by receipt of CPM compared with unilateral mastectomy at 6 months, 1 year, 2 years, and 3 years following reconstruction. RESULTS: Of 3334 women, 2040 (61%) underwent unilateral mastectomy and 1294 (39%) underwent CPM. Compared with White and Asian women who received CPM, Black women who underwent CPM were more likely to have higher BMI (p < 0.001), undergo autologous reconstruction (p = 0.006), and receive postmastectomy radiation (PMRT) (p < 0.001). There was no association between race and domains of satisfaction of breasts or psychosocial well-being for women who underwent unilateral mastectomy (p = 0.6 and p > 0.9, respectively) or CPM (p = 0.8 and p = 0.9, respectively). PMRT was negatively associated with both satisfaction with breasts (p < 0.001) and psychosocial well-being (p = 0.007). CONCLUSIONS: Differences in satisfaction with breasts and psychosocial well-being at 3-year follow-up were not associated with race but rather treatment variables, particularly the receipt of PMRT. Further investigations with a larger and more diverse population are needed to validate these findings.

Symmetric Breast Surgery: Balancing Procedures versus Prophylactic Mastectomy and Immediate Reconstruction.

BACKGROUND: Various techniques for management of the contralateral breast exist in patients with unilateral breast cancer, including contralateral prophylactic mastectomy with immediate breast reconstruction (PMIBR), and symmetrization techniques including augmentation, reduction, or mastopexy. The purpose of this prospective cohort study was to evaluate and compare complications and patient-reported satisfaction of patients with contralateral PMIBR versus having symmetrization procedures. METHODS: A 7-year, single-institution, prospectively maintained database was reviewed. Patient-reported BREAST-Q scores were obtained at baseline, 3 months, and 12 months prospectively. Postoperative complications, oncologic outcomes, and BREAST-Q scores were compared. RESULTS: A total of 249 patients were included, 93 (37%) of whom underwent contralateral PMIBR and 156 (63%) of whom underwent contralateral symmetrization. The patients who underwent PMIBR were younger and had less comorbidities compared with patients with symmetrization. Rates of major and minor complications were similar, apart from higher rates of minor wound dehiscence in the PMIBR group. When comparing mean change at 12-month follow-up to preoperative results, there was a significant decrease in physical well-being of the chest in the symmetrization compared with the PMIBR group (2.94 versus -5.69; P = 0.042). There were no significant differences in mean breast satisfaction and psychosocial well-being, and nonsignificant decreases in sexual well-being between groups. CONCLUSIONS: Patients with unilateral breast cancer who underwent immediate contralateral breast management, with either contralateral PMIBR or symmetrization techniques, demonstrated similar profiles of major complications and good overall satisfaction except for one physical well-being domain. Management of the contralateral breast with symmetrization may provide similar outcomes compared with PMIBR, which often is considered not necessary in patients without specific indications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Trends of incidence and mortality in metaplastic breast cancer and the effect of contralateral prophylactic mastectomy: A population-based study.

INTRODUCTION: Metaplastic breast cancer (MBC) is considered rare and aggressive. We examined the epidemiology of and prognostic factors for MBC and investigated the effect of contralateral prophylactic mastectomy (CPM), because neither had been thoroughly examined previously. METHODS: We obtained data from the Surveillance, Epidemiology, and End Results (SEER)-18(2000-2018) for epidemiological and survival analysis. RESULTS: The age-adjusted incidence per 100,000 persons of MBC increased significantly from 0.12 to 0.35 [annual percent change (APC):2.95%, 95% confidence interval [CI], 1.73-4.19]. The incidence-based mortality increased from 0.01 to 0.12 (APC: 5.01%, 95% CI: 2.50-7.58). The incidence of MBC patients who underwent CPM significantly increased from 0.003 to 0.039 with an APC of 10.96% (95%CI, 7.26-14.78). Older patients and those with higher T classification were less likely to receive CPM. The multivariate Cox model showed that CPM was not an independent predictor of good prognosis for both overall survival (OS) and breast cancer-specific survival (BCSS) (pre-propensity score matching (PSM): OS: P = 0.331; BCSS: P = 0.462. post-PSM: OS: P = 0.916; BCSS: P = 0.967). Subgroup analysis showed that CPM still did not provide a survival benefit to any risk groups. CONCLUSION: In this study, we demonstrated that the incidence and incidence-based mortality of MBC have increased over the past decades. Although the number of MBC patients who underwent CPM has significantly increased recently, CPM did not confer a survival benefit compared with unilateral mastectomy, indicating that the decision to undergo CPM should be considered carefully.

Assessment of the effect of the American Society of Breast Surgery guidelines on contralateral prophylactic mastectomy rates for unilateral breast cancer.

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 χ2 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.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy.

BACKGROUND: Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy. METHODS: A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected. RESULTS: In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients. CONCLUSIONS: There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Influence of contralateral prophylactic mastectomy on textbook outcome attainment at time of mastectomy.

INTRODUCTION: The objective of this study was to determine the incidence of textbook oncologic outcome (TOO) and its impact on overall survival (OS) among patients with invasive ductal carcinoma (IDC) following modified radical mastectomy (MRM) versus MRM with contralateral prophylactic mastectomy (MRM â€‹+ â€‹CPM). METHODS: The 2004-2017 National Cancer Database was queried for patients with IDC who underwent MRM and MRM â€‹+ â€‹CPM. TOO was defined as: resection with negative margins, adequate lymphadenectomy, length of stay ≤50th percentile, and no 30-day readmission or mortality. RESULTS: 87,573 patients were identified, of which 14.3% underwent MRM â€‹+ â€‹CPM. Logistic regression models revealed that MRM â€‹+ â€‹CPM is independently associated with a reduced likelihood of achieving TOO (AOR â€‹= â€‹0.71; P â€‹< â€‹0.001). MRM patients who achieved TOO had a higher median OS compared to those who did not (164.6 vs.142.2 months, P â€‹< â€‹0.001). CONCLUSIONS: MRM â€‹+ â€‹CPM is associated with a lower incidence of TOO attainment compared to MRM.

Top Breast Oncology Articles from 2021 to Inform Your Cancer Practice.

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.

Association of Moderate-Risk Breast Cancer Genes with Contralateral Prophylactic Mastectomy and Bilateral Disease.

BACKGROUND: The impact of ATM, CHEK2, and PALB2, the three most prevalent moderate-risk breast cancer genes, on surgical decision making is not well known. METHODS: Our retrospective study included patients with resectable non-metastatic breast cancer who underwent multigene panel testing between July 2014 and January 2020 with at least one genetic alteration (pathogenic or variant of uncertain significance [VUS] in ATM [n = 49], CHEK [n = 57], or PALB2 [n = 27]). Our objectives were to determine the rate of contralateral prophylactic mastectomy (CPM) and the rate of bilateral breast cancer. Univariable analyses (UVA) and multivariable analyses (MVA) were performed to identify factors associated with CPM and bilateral breast cancer. RESULTS: The rate of CPM was 39% (n = 49/127), with 54% (n = 25/46) of patients with a pathogenic mutation and 30% (n = 24/81) of patients with a VUS choosing CPM. On MVA, premenopausal status (odds ratio [OR] 3.46) and a pathogenic alteration (OR 3.01) were associated with increased use of CPM. Bilateral disease was noted in 16% (n = 22/138). Patients with pathogenic mutations had a 22% (n = 11/51) incidence of bilateral breast cancer, while patients with VUS had a 13% (n = 11/87) incidence, although this was not statistically significant on UVA or MVA. On MVA, premenopausal status was associated with a decreased risk of bilateral disease (OR 0.33, p = 0.022). During follow-up, a breast cancer event occurred in 16% (n = 22/138). CONCLUSIONS: Our study identified a high rate of CPM among those with ATM, CHEK2, and PALB2 alterations, including VUS. Further studies are needed to clarify reasons for CPM among patients with moderate-risk alterations.

Complication Rates in Therapeutic Versus Prophylactic Bilateral Mastectomies: Insights From a National Database.

BACKGROUND: The "Jolie effect" and other media focus on prophylactic treatments have resulted in unilateral breast cancer patients increasingly undergoing contralateral prophylactic mastectomy. Little is known, however, regarding outcomes following therapeutic versus prophylactic mastectomy. In this study, we compared complication rates of unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (BM-TP) to patients undergoing bilateral prophylactic mastectomy (BM-P). METHODS: The BM-TP and BM-P patients from 2015 to 2019 were identified in Optum Clinformatics DataMart. Six-month outcomes were assessed and included wound complications, infection, hematoma/seroma, breast pain, fat necrosis, flap failure, implant failure/removal, other flap/implant complications, and other complications. Multivariable regression models adjusted for age, residence, insurance, race, and Charlson Comorbidity Index score. RESULTS: Of 9319 women, 7114 (76.3%) underwent BM-TP, and 2205 (23.7%) underwent BM-P. In multivariable analysis, BM-TP had higher odds of overall complications (adjusted odds ratio [aOR], 1.35; P < 0.0001), but no difference was observed among patients who had autologous ( P = 0.1448) or no breast reconstruction ( P = 0.1530). Higher odds of overall complications persisted even after controlling for radiation therapy (aOR, 1.25; P = 0.0048) and chemotherapy (aOR, 1.28; P = 0.0047), but not after controlling for lymph node surgery ( P = 0.7765). CONCLUSION: The BM-TP (vs BM-P) patients face higher odds of overall complications but without any difference in certain reconstructive modalities or after controlling for lymph node surgery.

Satisfaction and Well-Being After Contralateral Prophylactic Mastectomy Among BRCA Mutation Carriers and Noncarriers: A Longitudinal Analysis of BREAST-Q Domains.

INTRODUCTION: Contralateral prophylactic mastectomy (CPM) is recommended for BRCA mutation carriers; its use in noncarriers relies on patient choice. We characterized differences in satisfaction and well-being after CPM between BRCA carriers and noncarriers. METHODS: BREAST-Q data were obtained before and after CPM with immediate reconstruction performed at a single institution from 2016 to 2022. Associations between BRCA status and satisfaction with breasts, psychosocial well-being, and sexual well-being were assessed, with adjustment for preoperative scores and relevant confounders. RESULTS: In total, 149 BRCA carriers and 842 noncarriers were included. Response rates varied over time (preoperative, 56%; 6 months, 78%; 1 year, 51%; 2 years, 52%; 3 years, 59%). BRCA carriers were younger (p < 0.001), with a higher rate of neoadjuvant chemotherapy (p < 0.001). More noncarriers had HR+/HER2- tumors (p < 0.001) and underwent endocrine therapy (p < 0.001). Baseline satisfaction with breasts was higher among BRCA carriers (median [interquartile range] score, 70 [53-82] vs. 58 [48-70]; p = 0.006); psychosocial (p = 0.20) and sexual (p = 0.14) well-being were not significantly different between groups. BRCA carriers had a greater decrease in satisfaction with breasts (p = 0.04) and psychological well-being (p = 0.05) from baseline to 6 months; decrease in sexual well-being (p = 0.38) was not significantly different between groups. On univariate and multivariable analyses, BRCA status was not associated with satisfaction with breasts, sexual well-being, or psychosocial well-being. CONCLUSIONS: Satisfaction and well-being were similar between BRCA carriers and noncarriers treated with CPM. Relative to noncarriers, BRCA carriers experienced a greater decline in satisfaction with breasts and psychological well-being at 6 months after CPM.