Mastectomía contralateral profiláctica / Contralateral prophylactic mastectomy

El cáncer de mama es el tumor más frecuente en la mujer. La mayoría de los carcinomas son esporádicos (70-80%)1, siendo una menor proporción los relacionados con antecedentes familiares y hereditarios (15-20%)1. En 1991 el National Institutes of Health publica un consenso en el que considera la cirugía conservadora del cáncer de mama en estadios iniciales (i-ii), la primera opción frente a la mastectomía, dado que la supervivencia era equiparable en las 2 opciones quirúrgicas2. La National Comprehensive Cancer Network3 también comparte este consenso. Sin embargo, en las 2 últimas décadas, la mastectomía contralateral profiláctica ha aumentado como cirugía reductora de riesgo. El objetivo de este estudio es realizar una revisión actualizada de la literatura científica más relevante sobre la mastectomía contralateral profiláctica como cirugía reductora de riesgo de cáncer de mama. Se analiza el riesgo de sufrir un cáncer de mama contralateral, así como la supervivencia global. Se abordan aspectos referentes al estudio de los factores influyentes en el aumento de las mastectomías contralaterales profilácticas, las técnicas relevantes de mastectomía y reconstrucción mamaria en la cirugía reductora de riesgo junto a sus complicaciones. Por último, se estudia el grado de satisfacción y de calidad de vida tras cirugía reductora de riesgo y el análisis de costes. (AU)

Breast cancer is the most common tumour in women. The majority of carcinomas are sporadic (70%-80%)1, and a smaller proportion is related to family and hereditary history (15%-20%)1. In 1991, the National Institutes of Health published a consensus that recommended conservative surgery for early stage breast cancer (I-II) as the first option over mastectomy, given that survival was similar in the 2 surgical options2. This recommendation is also made by the National Comprehensive Cancer Network3. However, in the last 2 decades, there has been an increase in the practice of prophylactic contralateral mastectomy as risk-reducing surgery. The aim of this study was to provide an up-to-date review of the most relevant scientific literature on prophylactic contralateral mastectomy and surgery to reduce the risk of breast cancer. The risk of contralateral breast cancer is analysed, as well as overall survival. The review discusses aspects related to the study of the factors influencing the increase in prophylactic contralateral mastectomies, the techniques of mastectomy and breast reconstruction in risk-reducing surgery, and its complications. Finally, we analyse the degree of satisfaction and quality of life after risk-reducing surgery and provide a cost analysis. (AU)

La mastectomía como medida de reducción de riesgo de cáncer de mama / Risk-reducing mastectomy in breast cancer

Objetivos: Evaluar las mastectomías reductoras de riesgo realizadas y analizar las indicaciones y resultados según las características individuales, oncológicas y quirúrgicas de nuestras pacientes.MétodosEstudio observacional retrospectivo de todas las mastectomías con reconstrucción inmediata en mamas sanas realizadas desde 2013 a 2019. Se dividieron las pacientes en tres grupos: I) riesgo genético de cáncer de mama, II) cáncer de mama diagnosticado y III) antecedente de cáncer de mama.ResultadosSe realizaron 56 mastectomías reductoras de riesgo a 46 pacientes, 15% grupo I, 50% grupo II y 35% grupo III, pero tras estudios diferidos, 20 pacientes (43%) presentaban mutación genética. La media de edad en este subgrupo fue de 40 años y con predominio de tumores HER2+ (40% frente al 12%, p=0,164). En el grupo III observamos más complicaciones inmediatas (31%, p=0,014) y tardías (69%, p=0,027) relacionadas con la reconstrucción protésica, y más evidente en mamas que tuvieron enfermedad (73% frente al 39% sanas, p=0,002). Se encontró relación entre contractura capsular y la radioterapia postoperatoria (p=0,008) y entre necrosis y radioterapia preoperatoria (p=0,001). Se reintervino al 7% por complicaciones en mastectomías profilácticas. No hemos tenido recidivas locales.ConclusionesConsideramos justificada la mastectomía reductora de riesgo realizada a mujeres jóvenes con mutación genética y a pacientes con cáncer precoz, HER2+ y riesgo familiar. En pacientes ya tratadas por cáncer, el riesgo de complicaciones supera el valor profiláctico de la técnica. La reconstrucción mamaria es la principal responsable de complicaciones postoperatorias y las pacientes deben ser plenamente conscientes de ello. (AU)

Objectives: To evaluate the risk-reducing mastectomies performed and to analyse the indications and results according to the individual, oncological and surgical characteristics of our patients.MethodsRetrospective observational study of all mastectomies with immediate reconstruction in healthy breasts performed from 2013 to 2019. The patients were divided into three groups: I) genetic risk of breast cancer, II) diagnosed breast cancer and III) history of cancer breast.ResultsA total of 56 risk-reducing mastectomies were performed in 46 patients, 15% in group I, 50% in group II and 35% in group III. After deferred studies, 20 (43%) patients had a genetic mutation. This subgroup had an average age of 40 years and a predominance of HER2+ tumours (40% versus 12%, p=0.164). In group III, we observed more immediate (31%, p=0.014) and late (69%, p=0.027) complications related to prosthetic reconstruction, which were more evident in breasts with disease (73% versus 39% healthy, p=0.002). A relationship was found between capsular contracture and postoperative radiotherapy (p=0.008) and between necrosis and preoperative radiotherapy (p=0.001). Reoperation was required in 7% for complications of prophylactic mastectomies. There were no local relapses.ConclusionsWe consider risk-reducing mastectomy to be justified in young women with a genetic mutation and in patients with early cancer, HER2+ and family risk. In patients already treated for cancer, the risk of complications exceeds the prophylactic value of the technique. Breast reconstruction is primarily responsible for postoperative complications and patients should be fully aware of this. (AU)

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.

Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia.

OBJECTIVES: Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia. MATERIALS AND METHODS: Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed. RESULTS: Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%). CONCLUSION: The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.

The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer.

Contralateral risk-reducing mastectomy (CRRM) rates have tripled over the last 2 decades. Reasons for this are multi-factorial, with those harbouring a pathogenic variant in the BRCA1/2 gene having the greatest survival benefit. On May 14th, 2013, Angelina Jolie shared the news of her bilateral risk-reducing mastectomy (BRRM), on the basis of her BRCA1 pathogenic variant status. We evaluated the impact of this news on rates of CRRM in women with increased risk for developing breast cancer after being diagnosed with unilateral breast cancer. The prospective cohort study included all women with at least a moderate lifetime risk of developing breast cancer who attended our family history clinic (1987-2019) and were subsequently diagnosed with unilateral breast cancer. Rates of CRRM were then compared between patients diagnosed with breast cancer before and after Angelina Jolie's announcement (pre- vs. post-AJ). Of 386 breast cancer patients, with a mean age at diagnosis of 48 ± 8 years, 268 (69.4%) were diagnosed in the pre-AJ period, and 118 (30.6%) in the post-AJ period. Of these, 123 (31.9%) underwent CRRM, a median 42 (interquartile range: 11-54) days after the index cancer surgery. Rates of CRRM doubled following AJ's news, from 23.9% pre-AJ to 50.0% post AJ (p < 0.001). Rates of CRRM were found to decrease with increasing age at breast cancer (p < 0.001) and tumour TNM stage (p = 0.040), and to increase with the estimated lifetime risk of breast cancer (p < 0.001) and tumour grade (p = 0.015) on univariable analysis. After adjusting for these factors, the step-change increase in CRRM rates post-AJ remained significant (odds ratio: 9.61, p < 0.001). The AJ effect appears to have been associated with higher rates of CRRM amongst breast cancer patients with increased cancer risk. CRRM rates were highest amongst younger women and those with the highest lifetime risk profile. Clinicians need to be aware of how media news can impact on the delivery of cancer related services. Communicating objective assessment of risk is important when counselling women on the merits of risk-reducing surgery.

Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer.

BACKGROUND: For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. METHODS: Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. RESULTS: Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models. CONCLUSIONS: Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.

Trends in Unilateral and Contralateral Prophylactic Mastectomy Use in Ductal Carcinoma In Situ of the Breast: Patterns and Predictors.

BACKGROUND: Increased use of contralateral prophylactic mastectomy (CPM) as treatment for ductal carcinoma in situ (DCIS) in the US was first noted in the early 2000s. Optimization of treatment guidelines for DCIS requires an understanding of current surgical treatment trends, particularly as they may differ by patient sociodemographic and community resource factors. OBJECTIVE: The aim of this study was to evaluate surgical treatment trends among US women with DCIS and to assess the impact of sociodemographic and community resource factors on surgical treatment choice. METHODS: The Surveillance, Epidemiology, and End Results dataset was queried for women aged 40 years and older who were diagnosed with unilateral DCIS between 2000 and 2014. Annual mastectomy rates were compared over time by age and race/ethnicity. Multivariable logistic regressions were performed to identify predictors of mastectomy use, with patient sociodemographics, tumor characteristics, and community resource factors (i.e. plastic surgeon density) as covariates. RESULTS: A total of 130,731 women with DCIS met the inclusion criteria. Overall mastectomy rates remained relatively unchanged over the study period (25-30%). CPM use increased for all age and race/ethnic groups, with the greatest increase exhibited by women aged 40-49 years [relative to 2000; 2014 odds ratio (OR) 10.6]. With respect to community resource factors, CPM use, as opposed to unilateral mastectomy, was associated with counties of higher education level (OR 1.52), higher income level (OR 1.22), and lower plastic surgeon density (OR 1.26). CONCLUSION AND RELEVANCE: While the popularity of mastectomy in the management of DCIS has remained relatively unchanged since the turn of the century, the use of CPM has risen substantially. Younger women with DCIS have seen the greatest increase in CPM use, a choice that remains influenced by race/ethnicity as well as income, education, and health resource availability. Until clinical risk stratifiers of DCIS are identified, the surgical decision-making paradigm must be improved so that treatment choice remains sensitive to cultural differences but becomes independent of income, education, and health resource availability.

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.

Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer.

BACKGROUND: The aim of this study was to evaluate the trends of surgical treatments among young patients in T1N0-1M0 stage based on the Surveillance, Epidemiology, and End Results database. MATERIALS AND METHODS: Patients aged less than 40 y diagnosed between 1998 and 2015 were enrolled, with tumors in T1N0-1M0 stage and not located in the central area. Differences in clinical-pathological characteristics were evaluated using chi-square tests. Multivariate logistic regression was used to measure the various factors associated with contralateral prophylactic mastectomy (CPM). Independent prognostic factors were evaluated by Cox model. RESULTS: The total rate of breast-conserving surgery (BCS) was 51.6%, which declined from 64.5% in 1998 to 39.6% in 2015. The total rate of CPM was 22.7%, which increased from 3.7% in 1998 to 38.7% in 2014 despite a decline to 32.7% in 2015. Meanwhile, the rate of reconstruction increased in line with that of CPM, from 9.4% in 1998 to 35.0% in 2015. There was a trend of increasing use of implant-based reconstruction. Significant higher odds of CPM were found in recent year of diagnosis between 2010 and 2015 and in implant-based reconstruction. Patients undergoing CPM had similar survival outcomes compared with those undergoing BCS and unilateral mastectomy, whereas those undergoing BCS had better survival outcomes compared with those undergoing unilateral mastectomy. CONCLUSIONS: A trend of growing preference for CPM and reconstruction was observed among young patients in early stage in recent years without survival benefits. Efforts should be made to promote efficient communication and evidence-based decision-making.

National trends in contralateral prophylactic mastectomy in women with locally advanced breast cancer.

BACKGROUND AND OBJECTIVES: Women with unilateral early-stage breast cancer are increasingly choosing contralateral prophylactic mastectomy (CPM) despite the absence of survival benefits and increased risk of surgical complications. Data are lacking on whether this trend extends to women with clinically locally advanced nonmetastatic (cT4M0) cancer. This study aims to estimate national CPM trends in women with unilateral cT4M0 breast cancer. METHODS: Women aged ≥ 18 years, who underwent mastectomy during 2004 to 2014 for unilateral cT4M0 breast cancer were identified using the National Cancer Database and grouped as all locally advanced (T4), chest wall invasion, skin nodule/ulceration, or both (T4abc), and inflammatory (T4d) cancer. Poisson regression for trends and logistic modeling for predictors of CPM were performed. RESULTS: Of 23 943 women, 41% had T4abc disease and 35% T4d. Cumulative CPM rates were 15%, 23%, and 18%, for the T4abc, T4d, and all T4 groups, respectively. Trend analysis revealed a significant upsurge in CPM demonstrating 12% annual growth for T4abc tumors, 8% for T4d and 9% for all T4 (all P < 0.001). CONCLUSIONS: Increasing numbers of women with unilateral cT4M0 breast cancer are undergoing CPM. This rising trend warrants further research to understand stakeholders' preferences in surgical decision-making for women with locally advanced breast cancer.

Trends in use of bilateral prophylactic mastectomy vs high-risk surveillance in unaffected carriers of inherited breast cancer syndromes in the Inherited Cancer Registry (ICARE).

PURPOSE: Awareness of inherited breast cancer has increased bilateral prophylactic mastectomy (BPM) among unaffected genetic mutation carriers, yet many still choose surveillance. We aimed to identify differences among women electing BPM vs high-risk surveillance. METHODS: Participants from an IRB-approved database recruited from 11/2000 to 01/2017 with a deleterious/pathogenic, variant suspected deleterious, or likely pathogenic mutation in ≥ 1 of 11 genes with increased risk for breast cancer (per 2017 NCCN guidelines) were identified. Participants with breast cancer and males were excluded. Sociodemographic and clinical data were collected. The BPM and high-risk surveillance groups were compared using Wilcoxon, Fisher's Exact, and Pearson's Chi-Square analyses. RESULTS: A total of 304 unaffected genetic mutation carriers were identified; 22 men were excluded. 113/282 (40%) underwent BPM. There was no significant difference in age, race, marital status, high school graduates, family history of breast cancer, breast biopsies, chemoprevention use, or understanding implications of genetic mutation carriage. BPM participants were more likely to have a prior pregnancy (p = 0.0005), college education (p = 0.04), income > $50,000/year (p = 0.01), first-degree relative with breast cancer (p = 0.04), higher total number of relatives with breast cancer (p = 0.01), and rate of risk-reducing salpingo-oophorectomy (p = < 0.0001). The high-risk surveillance group was more likely to have a history of ovarian cancer (p = 0.009) and cancer worry (p = < 0.0001). CONCLUSIONS: BPM is a common but not universal choice among unaffected genetic carriers of inherited breast cancer syndromes. Parity, education, income, ovarian cancer history, first-degree relatives with breast cancer, and cancer worry play significant roles in these decisions.

Trends in Contralateral Prophylactic Mastectomy and Other Types of Breast Cancer Surgery, South Carolina, 2005-2013.

BACKGROUND AND OBJECTIVES: Over the last decade, researchers have noted an increase in the rate of contralateral prophylactic mastectomy (CPM) across the United States despite the limited evidence on survival improvement associated with this surgery. Due to a lack of information on CPM in South Carolina, the authors of this study proposed to evaluate trends of different breast cancer surgery types with an emphasis on CPM rates. METHODS: A descriptive analysis was conducted regarding CPM in South Carolina among females who underwent surgery for breast cancer cases diagnosed from 2005-2013. The resulting data were compared over time with other type of surgeries performed. Data from the South Carolina Central Cancer Registry, a population-based cancer registry, were used to perform this analysis. RESULTS: Research revealed that 2,527 (7.41%) of females who were surgically treated for breast cancer underwent CPM. The rate increased from 4.21% in 2005 to 9.63% in 2013. Race differentials revealed that, for whites and blacks, the rates increased from 3.82% to 7.88% and from 0.3% to 1.57%, respectively. The non-Hispanic population CPM rate increased from 4.16% in 2005 to 9.61% in 2013; they represented 98.42% of the total number of CPMs performed. For Hispanics, the CPM rate increased from 9.68% in 2005 to 11.54% in 2013. The unilateral mastectomy rate decreased from 26.56% in 2005 to 23.99% in 2013. The breast-conserving surgery rate was steady. CONCLUSION: The CPM rate increased in South Carolina for breast cancer cases diagnosed from 2005-2013 among blacks, whites, non-Hispanics, and Hispanics. Further research should be done to identify the risks factors for CPM among females diagnosed with breast cancer in South Carolina.

Factors associated with the increasing trend of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ: Analysis of Surveillance, Epidemiology, and End Results data.

PURPOSE: Our study aimed to investigate the factors influencing trends of contralateral prophylactic mastectomy (CPM) among patients with unilateral ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) data to identify patients with unilateral DCIS diagnosed from 1998 to 2013. Patients were categorized as breast-conserving surgery (BCS), Unilateral Mastectomy and CPM group. Univariate and multivariate logistic regressions were applied to assess the factors associated with undergoing CPM among mastectomy patients. The trends of CPM among mastectomy patients through year were presented by different subgroups of sociodemographic and pathological characteristics. RESULTS: Of those, 105326 patients with DCIS were identified, and 6370 patients underwent CPM. The proportion of CPM was 6.05% for all surgically-treated patients and 21.09% for mastectomy patients, and it increased more than six-fold between 1998 and 2013 (from 1.74% to 10.89% for all surgically-treated patients and from 5.44% to 37.47% for mastectomy patients). Younger age, white race, married status, smaller tumor size, positive ER and PR status were significantly associated with higher CPM proportion among mastectomy patients. The proportion of CPM was increasing through year, and the increasing trends were obvious in the subgroups of younger, white, married, metropolitan, with higher bachelor degree and higher median family income patients, while there were no apparent differences in the trends between subgroups of pathological characteristics. CONCLUSION: The trends of CPM among mastectomy patients were increasing through years and influenced by patients' sociodemographic characteristics, but not pathological characteristics.

Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients.

BACKGROUND: Recent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution. METHODS: We identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction. RESULTS: A total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma. CONCLUSIONS: Our study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.

The Shifting Paradigm for Breast Cancer Surgery in Patients Undergoing Neoadjuvant Chemotherapy.

INTRODUCTION: Surgical therapy for newly diagnosed breast cancer has changed over the past decade, but these trends have not been well documented in patients undergoing neoadjuvant therapy (NAC). METHODS: In a retrospective cohort study of the National Cancer Database (NCDB), we selected 285,514 women with clinical stage I-III breast cancer who underwent NAC or adjuvant therapy (AC) from 2006 to 2014. Breast-conserving surgery (BCS), unilateral mastectomy (UM), and bilateral mastectomy (BM) rates were compared between patients undergoing NAC and AC. RESULTS: Of 285,514 women, 68,850 (24.1%) underwent NAC. Of NAC patients, 18,158 (26.4%) underwent BM and 27,349 (39.7%) BCS compared with 31,886 (14.7%) and 120,626 (55.7%) AC patients, respectively. From 2006 to 2014, BM increased from 16.1 to 28.8% (p < 0.001) for NAC and from 7.4 to 17.5% (p < 0.001) for AC. After adjusting for patient, tumor, and facility factors, NAC patients were 1.50 times [odds ratio (OR) 1.50, confidence interval (CI) 1.42-1.51] more likely to undergo BM then AC patients. The difference in BM rates between patients receiving NAC versus AC varied significantly by cT classification. This difference was the greatest among cT1 tumors between NAC and AC (31.7 vs. 13.0%, p < 0.001), followed by cT2 tumors (24.1 vs. 16.6%, p < 0.001) and cT3 tumors (24.3 vs. 22.3%). CONCLUSIONS AND RELEVANCE: More NAC patients are undergoing BM while fewer are undergoing BCS compared with patients undergoing AC. This trend is particularly striking for those patients with smaller tumors who would otherwise be candidates for BCS.

Decision Making in the Surgical Management of Invasive Breast Cancer-Part 1: Lumpectomy, Mastectomy, and Contralateral Prophylactic Mastectomy.

Several prospective randomized clinical trials conducted internationally have proven the safety and survival equivalence of breast-conserving surgery compared with mastectomy. Adjuvant radiation is routinely recommended following lumpectomy surgery to minimize the risk of local recurrence. Comprehensive breast imaging (including bilateral mammography with diagnostic views and ultrasound evaluation), in addition to clinical examination, is essential to rule out potential contralateral pathology and to optimally characterize the extent of disease. These studies are considered standard in the assessment of patient eligibility for lumpectomy. MRI of the breast remains controversial as an adjunct to determine candidacy for breast conservation, since MRI findings increase mastectomy rates without evidence of improved local control; prospective randomized clinical trials are underway to define the role of MRI in newly diagnosed breast cancer. Recently, the multidisciplinary oncology community has adopted a consensus guideline defining "no ink on tumor" as an acceptable microscopic margin at lumpectomy; however, post-lumpectomy imaging may be necessary to confirm complete removal of all cancer-associated microcalcifications, with clinical judgment exercised regarding re-excision for close margins. Contralateral prophylactic mastectomy is becoming increasingly common in the United States, and patients considering this option must be counseled about its lack of a survival benefit, its higher complication rate, and the fact that it is risk-reducing but not risk-eliminating.

State Variation in the Receipt of a Contralateral Prophylactic Mastectomy Among Women Who Received a Diagnosis of Invasive Unilateral Early-Stage Breast Cancer in the United States, 2004-2012.

Importance: The use of contralateral prophylactic mastectomies (CPMs) among patients with invasive unilateral breast cancer has increased substantially during the past decade in the United States despite the lack of evidence for survival benefit. However, whether this trend varies by state or whether it is correlated with changes in proportions of reconstructive surgery among these patients is unclear. Objective: To determine state variation in the temporal trend and in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery. Design, Setting, and Participants: A retrospective cohort study of 1.2 million women 20 years of age or older diagnosed with invasive unilateral early-stage breast cancer and treated with surgery from January 1, 2004, through December 31, 2012, in 45 states and the District of Columbia as compiled by the North American Association of Central Cancer Registries. Data analysis was performed from August 1, 2015, to August 31, 2016. Exposure: Contralateral prophylactic mastectomy. Main Outcomes and Measures: Temporal changes in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery by age and state, overall and in relation to changes in the proportions of those who underwent reconstructive surgery. Results: Among the 1 224 947 women with early-stage breast cancer treated with surgery, the proportion who underwent a CPM nationally increased between 2004 and 2012 from 3.6% (4013 of 113 001) to 10.4% (12 890 of 124 231) for those 45 years or older and from 10.5% (1879 of 17 862) to 33.3% (5237 of 15 745) for those aged 20 to 44 years. The increase was evident in all states, although the magnitude of the increase varied substantially across states. For example, among women 20 to 44 years of age, the proportion who underwent a CPM from 2004-2006 to 2010-2012 increased from 14.9% (317 of 2121) to 24.8% (436 of 1755) (prevalence ratio [PR], 1.66; 95% CI, 1.46-1.89) in New Jersey compared with an increase from 9.8% (162 of 1657) to 32.2% (495 of 1538) (PR, 3.29; 95% CI, 2.80-3.88) in Virginia. In this age group, CPM proportions for the period from 2010 to 2012 were over 42% in the contiguous states of Nebraska, Missouri, Colorado, Iowa, and South Dakota. From 2004 to 2012, the proportion of reconstructive surgical procedures among women aged 20 to 44 years who were diagnosed with early-stage breast cancer and received a CPM increased in many states; however, it did not correlate with the proportion of women who received a CPM. Conclusions and Relevance: The increase in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery varied substantially across states. Notably, in 5 contiguous Midwest states, nearly half of young women with invasive early-stage breast cancer underwent a CPM from 2010 to 2012. Future studies should examine the reasons for the geographic variation and increasing trend in the use of CPMs.

Motivations for contralateral prophylactic mastectomy as a function of socioeconomic status.

BACKGROUND: Despite no demonstrated survival advantage for women at average risk of breast cancer, rates of contralateral prophylactic mastectomy (CPM) continue to increase. Research reveals women with higher socioeconomic status (SES) are more likely to select CPM. This study examines how indicators of SES, age, and disease severity affect CPM motivations. METHODS: Patients (N = 113) who underwent CPM at four Indiana University affiliated hospitals completed telephone interviews in 2013. Participants answered questions about 11 CPM motivations and provided demographic information. Responses to motivation items were factor analyzed, resulting in 4 motivational factors: reducing long-term risk, symmetry, avoiding future medical visits, and avoiding treatments. RESULTS: Across demographic differences, reducing long-term risk was the strongest CPM motivation. Lower income predicted stronger motivation to reduce long-term risk and avoid treatment. Older participants were more motivated to avoid treatment; younger and more-educated patients were more concerned about symmetry. Greater severity of diagnosis predicted avoiding treatments. CONCLUSIONS: Reducing long-term risk is the primary motivation across groups, but there are also notable differences as a function of age, education, income, and disease severity. To stop the trend of increasing CPM, physicians must tailor patient counseling to address motivations that are consistent across patient populations and those that vary between populations.