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

Establishment and validation survival prediction models for T1 locally advanced breast cancer after breast conservation surgery versus mastectomy

Previous reports have indicated that the survival rate of total mastectomy (TM) is higher than that of breast-conserving surgery (BCS). This study established survival prediction models for T1-stage locally advanced breast cancer (LABC) comparing TM and BCS, aiming to identify risk factors for overall survival (OS) associated with different surgical approaches and provide a basis for individualized treatment by clinicians. Cases of pathologically confirmed T1 LABC between 2010 and 2015 were retrieved from the Surveillance Epidemiology and End Results (SEER) database. COX regression analysis was used to analyze the relationship between LABC TM, BCS and various factors. Hazard ratio (HR) and 95% confidence interval (95%CI) were calculated to determine the possible influencing factors. Significant factors from multivariate COX regression were included into the models construct nomograms. Receiver operating characteristic curves (ROC), area under the curve of ROC (AUC), calibration curves, and the Hosmer-Lemeshow goodness-of-fit test for the calibration curves were generated. Model validation was conducted in a separate validation group. The results of COX regression analysis on survival rates for T1 LABC patients undergoing TM and BCS showed that the 5-year overall survival (OS) and breast cancer-specific survival (BCSS) were higher in the BCS group compared to the TM group. Age, race, histological grade, N stage, molecular subtype, chemotherapy, and radiation therapy (RT) were associated with 5-year OS of BCS. Similarly, age, race, pathological type, histological grade, human epidermal growth factor receptor 2 (HER2) status, N stage, molecular subtype, chemotherapy, and RT were correlated with 5-year OS of TM. Prediction nomograms were established using the aforementioned predictors, resulting in AUCs of 0.743 (for 5-year OS of BCS) and 0.718 (for 5-year OS of TM) in the modeling group. Both models were well-validated in the validation group. This study found that the survival rate of the BCS group was higher than that of the TM group, indicating that tumor size determines the survival rate of BCS to some extent. Lymph node status cannot be considered a contraindication for BCS surgery, suggesting that BCS can be considered for LABC patients with smaller tumors and more lymph node metastases. However, patients with primary tumors in N3 stage, triple-negative, and inner upper quadrant have a higher risk of death after BCS compared to other groups, so BCS should be carefully considered for these patients.

Risk of second primary cancer in young breast cancer survivors: an important yet overlooked issue

Currently, female breast cancer (BC) represents the highest incidence of cancer globally. This trend has raised significant attention regarding breast cancer young women (BCYW). With advancements in treatment technology, BCYW survivors are living longer; however, the risk of developing or succumbing to a second primary cancer (SPC) has greatly increased. In addition, several factors, including age, menstrual cycle, hormonal changes, obesity, pregnancy, and breastfeeding, interact to influence the development of SPC in BCYW and make its treatment more difficult. This study investigates the relationship between BCYW and SPC, focusing on morbidity trends, pathological genomics, recurrence rates, survival times, treatment modalities, and physiological fertility. Most BCYW involve BRCA pathogenic variants or fall under triple-negative and human epidermal growth factor receptor 2-overexpressing subtypes, increasing the risk of SPC. While there are regional variations in survival time following the diagnosis of an SPC, the long-term survival outcomes remain unfavorable. In addition, the choice of treatment for BCYW survivors has a prolonged cumulative toxic effect. The combination of endocrine therapy and chemotherapy is effective in treating BC, but it simultaneously increases the risk of developing an SPC, specifically endometrial cancer. Furthermore, radiotherapy is associated with a heightened risk of contralateral BC and lung cancer. We aim to address existing gaps in the literature and to enhance awareness of the risks associated with SPC in BCYW, thereby offering valuable insights for clinical diagnosis and treatment.

The Use of Unlisted Billing Codes for Microsurgical Breast Reconstruction and Implications for Code Consolidation

BACKGROUND

 Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers.

METHODS

 Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes.

RESULTS

 There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients.

CONCLUSION

 Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.

Bilateral Mastectomy and Breast Cancer Mortality

Importance

The benefit of bilateral mastectomy for women with unilateral breast cancer in terms of deaths from breast cancer has not been shown.

Objectives

To estimate the 20-year cumulative risk of breast cancer mortality among women with stage 0 to stage III unilateral breast cancer according to the type of initial surgery performed.

Design, Settings, and Participants

This cohort study used the Surveillance, Epidemiology, and End Results (SEER) Program registry database to identify women with unilateral breast cancer (invasive and ductal carcinoma in situ) who were diagnosed from 2000 to 2019. Three closely matched cohorts of equal size were generated using 1:1:1 matching according to surgical approach. The cohorts were followed up for 20 years for contralateral breast cancer and for breast cancer mortality. The analysis compared the 20-year cumulative risk of breast cancer mortality for women treated with lumpectomy vs unilateral mastectomy vs bilateral mastectomy. Data were analyzed from October 2023 to February 2024.

Exposures

Type of breast surgery performed (lumpectomy, unilateral mastectomy, or bilateral mastectomy).

Main Outcomes and Measures

Contralateral breast cancer or breast cancer mortality during the 20-year follow-up period among the groups treated with lumpectomy vs unilateral mastectomy vs bilateral mastectomy.

Results

The study sample included 661 270 women with unilateral breast cancer (mean [SD] age, 58.7 [11.3] years). After matching, there were 36 028 women in each of the 3 treatment groups. During the 20-year follow-up, there were 766 contralateral breast cancers observed in the lumpectomy group, 728 contralateral breast cancers in the unilateral mastectomy group, and 97 contralateral cancers in the bilateral mastectomy group. The 20-year risk of contralateral breast cancer was 6.9% (95% CI, 6.1%-7.9%) in the lumpectomy-unilateral mastectomy group. The cumulative breast cancer mortality was 32.1% at 15 years after developing a contralateral cancer and was 14.5% for those who did not develop a contralateral cancer (hazard ratio, 4.00; 95% CI, 3.52-4.54, using contralateral breast cancer as a time-dependent covariate). Deaths from breast cancer totaled 3077 women (8.54%) in the lumpectomy group, 3269 women (9.07%) in the unilateral mastectomy group, and 3062 women (8.50%) in the bilateral mastectomy group.

Conclusions and Relevance

This cohort study indicates that the risk of dying of breast cancer increases substantially after experiencing a contralateral breast cancer. Women with breast cancer treated with bilateral mastectomy had a greatly diminished risk of contralateral breast cancer; however, they experienced similar mortality rates as patients treated with lumpectomy or unilateral mastectomy.

Epidemiology and prognostic nomogram for invasive breast cancer aged 85 years and older in the USA

The available data on epidemiology and prognostic factors of female patients with breast cancer aged 85 years and older in the USA are limited, especially regarding molecular-level heterogeneity. Relevant data were extracted from the surveillance, epidemiology, and end-result database. The incidence rate and the annual prevalence rate were determined. The annual percent change (APC) of incidence was measured to determine the gradual trends or changes in rates. A visual nomogram was constructed to predict the 3-year overall survival (OS). The Kaplan-Meier method and log-rank test were performed for survival analysis. In total, 18,137 female patients with invasive breast cancer aged 85 years and older were included. Among these patients, patients with HR+/HER2- accounted for 68.7%, followed by HR-/HER2- (9.3%), HR+/HER2+ (7.4%), and HR-/HER2+ (3.1%). The overall incidence rate among this population was 181.82 (95% CI 179.18-184.49) per 100,000 women. This decreased from 184.73 to 177.71 per 100,000 women from 2010 to 2019, with an APC of - 1.0 (95% CI - 1.8 to - 0.1, P = 0.036). The incidence rate varied across receptor subtypes and races and was higher in patients with HR+/HER2- or the black population. The most common treatment regime was breast-conserving surgery. Approximately 29.2% of all patients were categorized as receiving no treatment. A nomogram for predicting 3-year overall survival was constructed, with a consistency index of 0.71. Furthermore, the calibration curves showed consistency. In this study, we have presented the epidemiological data of invasive breast cancer in females aged 85 years and older in the USA. The developed predictive nomogram can effectively identify patients with poor survival.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks

Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.

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.

Contralateral prophylactic mastectomy in a rural population: A single-institution experience

Background

The incidence of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer (UBC) has continued to increase, despite an absent survival benefit except in populations at highest risk for developing contralateral breast cancer (CBC). CPM rates may be higher in rural populations but causes remain unclear. A study performed at our institution previously found that 21.8 % of patients with UBC underwent CPM from 2000 to 2009. This study aimed to evaluate the CPM trend at a single institution serving a rural population and identify the CPM rate in average-risk patients.

Methods

Retrospective review of patients who underwent mastectomies for UBC at our institution from 2017 to 2021 was performed. Analysis utilized frequencies and percentages, descriptive statistics, chi-square, and independent sample t-tests.

Results

A total of 438 patients were included, of whom 64.4 % underwent bilateral mastectomy for UBC (CPM). Patients who underwent CPM were significantly younger, underwent genetic testing, had germline pathogenic variants, had a family history of breast cancer, had smaller tumors, underwent reconstruction, and had more wound infections. Of CPM patients, 50.4 % had no identifiable factors for increased risk of developing CBC.

Conclusions

The rate of CPM in a rural population at a single institution increased from 21.8 % to 64.4 % over two decades, with an average-risk CPM rate of 50.4 %. Those that undergo CPM are more likely to undergo reconstruction and have more wound infections. Identifying characteristics of patients undergoing CPM in a rural population and the increased associated risks allows for a better understanding of this trend to guide conversations with patients.

Key message

This study demonstrates that the rate of contralateral prophylactic mastectomy for unilateral breast cancers performed at a single institution serving a largely rural population has nearly tripled over the last two decades, with half of these patients having no factors that increase the risk for developing contralateral breast cancers. Contralateral prophylactic mastectomy was significantly associated with smaller tumors, younger age, genetic testing, germline pathogenic variants, family history of breast cancer, breast reconstruction, and increased wound infections.

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 ​+ ​CPM).

METHODS

The 2004-2017 National Cancer Database was queried for patients with IDC who underwent MRM and MRM ​+ ​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 ​+ ​CPM. Logistic regression models revealed that MRM ​+ ​CPM is independently associated with a reduced likelihood of achieving TOO (AOR ​= ​0.71; P ​< ​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 ​< ​0.001).

CONCLUSIONS

MRM ​+ ​CPM is associated with a lower incidence of TOO attainment compared to MRM.

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.

Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer

PURPOSE

Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.

METHODS

Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.

RESULTS

Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).

CONCLUSION

The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Survival Outcomes in Women with Unilateral, Triple-Negative, Breast Cancer Correlated with Contralateral Prophylactic Mastectomy

BACKGROUND

Despite increased utilization of contralateral prophylactic mastectomy (CPM), there is insufficient evidence that it improves survival in average-risk women with unilateral breast cancer. CPM may be of heightened interest to patients with triple negative breast cancer (TNBC) because these patients are more likely to have BRCA1 mutation-associated disease and are not candidates for the chemoprevention benefits of adjuvant endocrine therapy.

METHODS

Survival and recurrence outcomes were evaluated for all TNBC patients from a multi-institutional database (1999-2018) at two academic cancer programs in two metropolitan cities of the Northeast and Midwest. Median follow-up time was 3.7 years.

RESULTS

Seven hundred and nighty six TNBC patients were evaluated and 15.45% underwent CPM. Women undergoing CPM were more likely to be white (p < 0.001), younger (p < 0.001), and underwent genetic testing (p < 0.001). A borderline survival benefit was observed for TNBC patients undergoing CPM (5-year overall survival 95.1% vs. 85.0%; p = 0.05). There was no difference in survival when BRCA mutation carriers were excluded (5-year overall survival 94.1% vs. 85.2%; p = 0.12). For BRCA mutation carriers, a numeric trend was observed for improved survival for patients undergoing CPM (5-year overall survival 97.2% vs. 84.1%; p = 0.35). Among patients not undergoing CPM, the rate of developing a new primary breast cancer was 2.2% (15/673). Among these 15 patients, 20% (3/15) were known BRCA mutation carriers.

CONCLUSIONS

Our data demonstrate no survival benefit for TNBC patients without BRCA1/2 mutations undergoing CPM.

Does a brief surgeon training in negotiation theory principles decrease rates of contralateral prophylactic mastectomy?

PURPOSE

Despite the lack of any oncologic benefit, contralateral prophylactic mastectomy (CPM) use among women with unilateral breast cancer is increasing. This patient-driven trend is influenced by fear of recurrence and desire for peace of mind. Traditional educational strategies have been ineffective in reducing CPM rates. Here we employ training in negotiation theory strategies for counseling and determine the effect on CPM rates.

METHODS

In consecutive patients with unilateral breast cancer treated with mastectomy from 05/2017 to 12/2019, we examined CPM rates before and after a brief surgeon training in negotiation skills. This comprised a systematic framework for patient counseling utilizing early setting of the default option, leveraging social proof, and framing.

RESULTS

Among 2144 patients, 925 (43%) were treated pre-training and 744 (35%) post-training. Those treated in the 6-month transition period were excluded (n = 475, 22%). Median patient age was 50 years; most patients had T1-T2 (72%), N0 (73%), and estrogen receptor-positive (80%) tumors of ductal histology (72%). The CPM rate was 47% pre-training versus 48% post-training, with an adjusted difference of -3.7% (95% CI -9.4 to 2.1, p = 0.2). In a standardized self-assessment survey, all 15 surgeons reported a high baseline use of negotiation skills and no significant change in conversational difficulty with the structured approach.

CONCLUSION

Brief surgeon training did not affect self-reported use of negotiation skills or reduce CPM rates. The choice of CPM is a highly individual decision influenced by patient values and decision styles. Further research to identify effective strategies to minimize surgical overtreatment with CPM is needed.

Decision-making experiences of breast cancer patients related to contralateral prophylactic mastectomy-a systematic meta-synthesis of qualitative studies

PURPOSE

Currently, the choice of contralateral prophylactic mastectomy (CPM) for breast cancer patients is variable and controversial. Breast cancer patients must make complex and rapid decisions based on the benefits and risks of CPM. Although there are many qualitative studies on the decision-making experiences of breast cancer patients, there is a lack of synthesis of these qualitative studies. Our study goals were to conduct a meta-synthesis of qualitative studies on the decision-making experiences, real-life experiences, psychological feelings and needs of breast cancer patients in CPM decision-making, with the aim of providing information to support the development of CPM practice decisions.

METHODS

Using a meta-ethnographic approach, qualitative research studies were analysed and synthesised using the method of "reciprocal translational analysis", and themes related to the decision-making experiences of breast cancer patients with respect to CPM were identified.

RESULTS

Five hundred ninety-three documents were retrieved. This meta-synthesis ultimately collected 8 studies. Four themes were identified: (1) decision motivations for survival and body intention; (2) negative and vacillating decision emotions; (3) diverse but weak decision support; (4) short-term satisfaction but long-term unknown and differentiated decision effects.

CONCLUSIONS

We found that although patients had different feelings about the effects of CPM in detail, most patients were satisfied with the short-term effects of CPM, but the long-term effects of CPM were still unknown. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in May 2022 (Registration number: CRD42022334260).

EBCC-13 manifesto: Balancing pros and cons for contralateral prophylactic mastectomy

After a diagnosis of unilateral breast cancer, increasing numbers of patients are requesting contralateral prophylactic mastectomy (CPM), the surgical removal of the healthy breast after diagnosis of unilateral breast cancer. It is important for the community of breast cancer specialists to provide meaningful guidance to women considering CPM. This manifesto discusses the issues and challenges of CPM and provides recommendations to improve oncological, surgical, physical and psychological outcomes for women presenting with unilateral breast cancer: (1) Communicate best available risks in manageable timeframes to prioritise actions; better risk stratification and implementation of risk-assessment tools combining family history, genetic and genomic information, and treatment and prognosis of the first breast cancer are required; (2) Reserve CPM for specific situations; in women not at high risk of contralateral breast cancer (CBC), ipsilateral breast-conserving surgery is the recommended option; (3) Encourage patients at low or intermediate risk of CBC to delay decisions on CPM until treatment for the primary cancer is complete, to focus on treating the existing disease first; (4) Provide patients with personalised information about the risk:benefit balance of CPM in manageable timeframes; (5) Ensure patients have an informed understanding of the competing risks for CBC and that there is a realistic plan for the patient; (6) Ensure patients understand the short- and long-term physical effects of CPM; (7) In patients considering CPM, offer psychological and surgical counselling before surgery; anxiety alone is not an indication for CPM; (8) Eliminate inequality between countries in reimbursement strategies; CPM should be reimbursed if it is considered a reasonable option resulting from multidisciplinary tumour board assessment; (9) Treat breast cancer patients at specialist breast units providing the entire patient-centred pathway.

The Contribution of Germline Pathogenic Variants in Breast Cancer Genes to Contralateral Breast Cancer Risk in BRCA1/BRCA2/PALB2-Negative Women

BACKGROUND

Contralateral breast cancer (CBC) is associated with younger age at first diagnosis, family history and pathogenic germline variants (PGVs) in genes such as BRCA1, BRCA2 and PALB2. However, data regarding genetic factors predisposing to CBC among younger women who are BRCA1/2/PALB2-negative remain limited.

METHODS

In this nested case-control study, participants negative for BRCA1/2/PALB2 PGVs were selected from the WECARE Study. The burden of PGVs in established breast cancer risk genes was compared in 357 cases with CBC and 366 matched controls with unilateral breast cancer (UBC). The samples were sequenced in two phases. Whole exome sequencing was used in Group 1, 162 CBC and 172 UBC (mean age at diagnosis: 42 years). A targeted panel of genes was used in Group 2, 195 CBC and 194 UBC (mean age at diagnosis: 50 years). Comparisons of PGVs burdens between CBC and UBC were made in these groups, and additional stratified sub-analysis was performed within each group according to the age at diagnosis and the time from first breast cancer (BC).

RESULTS

The PGVs burden in Group 1 was significantly higher in CBC than in UBC (p = 0.002, OR = 2.5, 95CI: 1.2-5.6), driven mainly by variants in CHEK2 and ATM. The proportions of PGVs carriers in CBC and UBC in this group were 14.8% and 5.8%, respectively. There was no significant difference in PGVs burden between CBC and UBC in Group 2 (p = 0.4, OR = 1.4, 95CI: 0.7-2.8), with proportions of carriers being 8.7% and 8.2%, respectively. There was a significant association of PGVs in CBC with younger age. Metanalysis combining both groups confirmed the significant association between the burden of PGVs and the risk of CBC (p = 0.006) with the significance driven by the younger cases (Group 1).

CONCLUSION

In younger BRCA1/BRCA2/PALB2-negative women, the aggregated burden of PGVs in breast cancer risk genes was associated with the increased risk of CBC and was inversely proportional to the age at onset.

Breast Cancer Statistics, 2022

This article is the American Cancer Society's update on female breast cancer statistics in the United States, including population-based data on incidence, mortality, survival, and mammography screening. Breast cancer incidence rates have risen in most of the past four decades; during the most recent data years (2010-2019), the rate increased by 0.5% annually, largely driven by localized-stage and hormone receptor-positive disease. In contrast, breast cancer mortality rates have declined steadily since their peak in 1989, albeit at a slower pace in recent years (1.3% annually from 2011 to 2020) than in the previous decade (1.9% annually from 2002 to 2011). In total, the death rate dropped by 43% during 1989-2020, translating to 460,000 fewer breast cancer deaths during that time. The death rate declined similarly for women of all racial/ethnic groups except American Indians/Alaska Natives, among whom the rates were stable. However, despite a lower incidence rate in Black versus White women (127.8 vs. 133.7 per 100,000), the racial disparity in breast cancer mortality remained unwavering, with the death rate 40% higher in Black women overall (27.6 vs. 19.7 deaths per 100,000 in 2016-2020) and two-fold higher among adult women younger than 50 years (12.1 vs. 6.5 deaths per 100,000). Black women have the lowest 5-year relative survival of any racial/ethnic group for every molecular subtype and stage of disease (except stage I), with the largest Black-White gaps in absolute terms for hormone receptor-positive/human epidermal growth factor receptor 2-negative disease (88% vs. 96%), hormone receptor-negative/human epidermal growth factor receptor 2-positive disease (78% vs. 86%), and stage III disease (64% vs. 77%). Progress against breast cancer mortality could be accelerated by mitigating racial disparities through increased access to high-quality screening and treatment via nationwide Medicaid expansion and partnerships between community stakeholders, advocacy organizations, and health systems.

Tools for Contralateral Prophylactic Mastectomy Decision Making

PURPOSE

Women with unilateral breast cancer are increasingly opting for the removal of not only the involved breast, but also for the removal of the opposite uninvolved breast (contralateral prophylactic mastectomy [CPM]), although the risk of contralateral breast cancer (CBC) has decreased in recent years. Models to predict the absolute risk of CBC can help a woman decide whether to undergo CPM. Our objective is to illustrate that a better decision can be made if the patient and doctor also have estimates of the absolute risks of regional and distant recurrences and mortality from non-breast cancer causes.

MATERIALS AND METHODS

We based our analyses on two published models for CBC and published information on the hazards of regional and distant recurrences and non-breast cancer mortality. Assuming that CPM eliminates CBC but has no effect on other events, we calculated how much CPM reduces a woman's CBC risk and total risk from all these events for 10 hypothetical women with various subtypes of breast cancer and risk factors.

RESULTS

The risk of CBC and total risk vary greatly, depending on the breast cancer subtype. In some cases, a decision for or against CPM can be based on CBC risk alone, but in others, additional consideration of total risk may cause a woman to decline CPM.

CONCLUSION

There is a potential to develop more informative tools for deciding on CPM. Realizing this potential will require more and better data to validate existing models of absolute CBC risk and to characterize the hazards of regional and distant recurrences and deaths from non-breast cancer causes for women with various subtypes of breast cancers and risk factors.

Cancer treatment and survivorship statistics, 2022

The number of cancer survivors continues to increase in the United States due to the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate triennially to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries, vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics, and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Database are presented for the most prevalent cancer types by race, and cancer-related and treatment-related side-effects are also briefly described. More than 18 million Americans (8.3 million males and 9.7 million females) with a history of cancer were alive on January 1, 2022. The 3 most prevalent cancers are prostate (3,523,230), melanoma of the skin (760,640), and colon and rectum (726,450) among males and breast (4,055,770), uterine corpus (891,560), and thyroid (823,800) among females. More than one-half (53%) of survivors were diagnosed within the past 10 years, and two-thirds (67%) were aged 65 years or older. One of the largest racial disparities in treatment is for rectal cancer, for which 41% of Black patients with stage I disease receive proctectomy or proctocolectomy compared to 66% of White patients. Surgical receipt is also substantially lower among Black patients with non-small cell lung cancer, 49% for stages I-II and 16% for stage III versus 55% and 22% for White patients, respectively. These treatment disparities are exacerbated by the fact that Black patients continue to be less likely to be diagnosed with stage I disease than White patients for most cancers, with some of the largest disparities for female breast (53% vs 68%) and endometrial (59% vs 73%). Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based strategies and equitable access to available resources are needed to mitigate disparities for communities of color and optimize care for people with a history of cancer. CA Cancer J Clin. 2022;72:409-436.

Automated assessment of breast margins in deep ultraviolet fluorescence images using texture analysis

Microscopy with ultraviolet surface excitation (MUSE) is increasingly studied for intraoperative assessment of tumor margins during breast-conserving surgery to reduce the re-excision rate. Here we report a two-step classification approach using texture analysis of MUSE images to automate the margin detection. A study dataset consisting of MUSE images from 66 human breast tissues was constructed for model training and validation. Features extracted using six texture analysis methods were investigated for tissue characterization, and a support vector machine was trained for binary classification of image patches within a full image based on selected feature subsets. A weighted majority voting strategy classified a sample as tumor or normal. Using the eight most predictive features ranked by the maximum relevance minimum redundancy and Laplacian scores methods has achieved a sample classification accuracy of 92.4% and 93.0%, respectively. Local binary pattern alone has achieved an accuracy of 90.3%.

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.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.

Timely cancer genetic counseling and testing for young women with breast cancer: impact on surgical decision-making for contralateral risk-reducing mastectomy

PURPOSE

Genetic testing (GT) can identify individuals with pathogenic/likely pathogenic variants (PV/LPVs) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic.

METHODS

Clinical data were reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤ 45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated.

RESULTS

Of the 194 patients, 30 (15.5%) had a PV/LPV in a BC predisposition gene (ATM, BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV/LPV carriers and 42/164 (25.6%) non-carriers. A positive test result (p < 0.01) and significant family history were associated with CRRM (p = 0.02). For the 164 with uninformative results, multivariate analysis showed that CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.10), or BC stage (p = 0.11).

CONCLUSION

In this cohort of young women with BC, the identification of a PV/LPV in a BC predisposition gene and a significant family history were associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.

A Comparison of Complications in Therapeutic versus Contralateral Prophylactic Mastectomy Reconstruction: A Paired Analysis

BACKGROUND

Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear.

METHODS

Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient.

RESULTS

A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)].

CONCLUSION

Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Toward a better understanding of the experience of patients with moderate penetrance breast cancer gene pathogenic/likely pathogenic variants: A focus on ATM and CHEK2

This study explored the experiences of patients with pathogenic or likely pathogenic variants in the moderate penetrance breast cancer genes, ATM and CHEK2. There were 139 eligible female patients who received genetic counseling at the Massachusetts General Hospital Center for Cancer Risk Assessment (MGH CCRA) from 2014 to 2018. They were sent surveys assessing their understanding of the clinical significance of their genetic test results, adherence to medical management recommendations, dissemination of genetic test results to relatives, and informational resource needs. In total, 66 surveys were returned with a response rate of 47.5%. Most participants reported understanding the clinical implications of their genetic test results and adhering to medical management recommendations. Although 20.3% found it upsetting, nearly all participants shared their genetic test results with relatives. When asked about resource needs, 54.5% reported seeking out additional resources. Our ATM/CHEK2 sample appears to have a good understanding of the personal and familial implications of their genetic test results but may benefit from additional resources. It is unclear whether similar results would be found in patients who do not receive genetic counseling from a board-certified genetic counselor, and this should be examined. This study is one of the first to assess the experiences and needs of the moderate risk population.

Rural-urban differences in secular trends of locoregional treatment for ductal carcinoma in situ: A patterns of care analysis

Precis

Omission of PORT following BCS remains high among rural patients despite evidence that PORT leads to a significant reduction in the risk of local recurrence. Further research is needed to examine the impact of rural residence on treatment choices and develop methods to ensure equitable care among all breast cancer patients.

Background

Despite national guidelines, debate exists among clinicians regarding the optimal approach to treatment for patients diagnosed with ductal carcinoma in situ (DCIS). While regional variation in practice patterns has been well documented, population‐based information on rural–urban treatment differences is lacking.

Methods

Data from the SEER Patterns of Care studies were used to identify women diagnosed with histologically confirmed DCIS who underwent cancer‐directed surgery in the years 1991, 1995, 2000, 2005, 2010, and 2015. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using weighted multivariable logistic regression to evaluate cancer‐directed surgery and use of post‐operative radiation therapy (PORT).

Results

Of the 3337 patients who met inclusion criteria, 27% underwent mastectomy, 26% underwent breast‐conserving surgery (BCS) without PORT, and 47% underwent BCS with PORT. After adjustment for other covariates, there was no difference in the likelihood of receiving mastectomy between rural and urban patients (aOR = 0.65; 95% CI 0.37–1.14). However, rural residents were more likely than urban residents to have mastectomy during 1991/1995 (aOR = 1.78; 95% CI 1.09–2.91; p_interaction = 0.022). Across all diagnosis years, patients residing in rural areas were less likely to receive PORT following BCS compared to urban patients (aOR = 0.35; 95% CI 0.18–0.67).

Conclusions

Omission of PORT following BCS remains high among rural patients despite evidence that PORT leads to a significant reduction in the risk of local recurrence. Further research is needed to examine the impact of rural residence on treatment choices and develop methods to ensure equitable care among all breast cancer patients.

Statewide Episode Spending Variation of Mastectomy for Breast Cancer

BACKGROUND

Centralizing complex cancer operations, such as pancreatectomy and esophagectomy, has been shown to increase value, largely due to reduction in complications. For high-volume operations with low complication rates, it is unknown to what degree value varies between facilities, or by what mechanism value may be improved. To identify possible opportunities for value enhancement for such operations, we sought to describe variations in episode spending for mastectomy with a secondary aim of identifying patient- and facility-level determinants of variation.

STUDY DESIGN

Using the Michigan Value Collaborative risk-adjusted, price-standardized claims data, we evaluated mean spending for patients undergoing mastectomy at 74 facilities (n = 7,342 patients) across the state of Michigan. Primary outcomes were 30- and 90-day episode spending. Using linear mixed models, facility- and patient-level factors were explored for association with spending variability.

RESULTS

Among 7,342 women treated across 74 facilities, mean 30-day spending by facility ranged from $11,129 to $20,830 (median $14,935). Ninety-day spending ranged from $17,303 to $31,060 (median $23,744). Patient-level factors associated with greater spending included simultaneous breast reconstruction, bilateral surgery, length of stay, and readmission. Among women not undergoing reconstruction, variation persisted, and length of stay, bilateral surgery, and readmission were all associated with increased spending.

CONCLUSION

Michigan hospitals have significant variation in spending for mastectomy. Reducing length of stay through wider adoption of same-day discharge for mastectomy and reducing the frequency of bilateral surgery may represent opportunities to increase value, without compromising patient safety or oncologic outcomes.

Breast Cancer Disparities and the Impact of Geography

Neighborhood has significant implications for breast cancer screening, stage, treatment, and mortality. Patients residing in neighborhoods with high deprivation or rurality face barriers and challenges to accessing and receiving care. Consequently, they experience higher mortality rates than their financially affluent or urban counterparts. There are multiple gaps in the literature on the relationship between place of residence and the use of systemic therapies or emerging surgical strategies for disease management. As the management of breast cancer continues to evolve, additional studies are needed to understand the implications of place on the implementation and dissemination of new and emerging treatment modalities.

High Compliance With Choosing Wisely Breast Surgical Guidelines at a Safety-Net Hospital

BACKGROUND

Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital.

METHODS

We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test.

RESULTS

Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020.

CONCLUSIONS

De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.

Controversies in Breast Cancer Surgery

Breast surgical oncology is a rapidly evolving field with significant advances shaped by practice-changing research. Three areas of ongoing controversy are (1) high rates of contralateral prophylactic mastectomy (CPM) in the United States despite uncertain benefit, (2) indications for and use of neoadjuvant chemotherapy (NACT) and endocrine therapy (NET), and (3) staging and treatment of the axilla, particularly after neoadjuvant systemic therapy. We discuss the patient populations for whom CPM may or may not be beneficial, indications for NACT and NET, and the trend toward de-escalation of locoregional axillary treatment.

Multifocality and Multicentrality in Breast Cancer: Comparison of the Efficiency of Mammography, Contrast-Enhanced Spectral Mammography, and Magnetic Resonance Imaging in a Group of Patients with Primarily Operable Breast Cancer

BACKGROUND

The multifocality and multicentrality of breast cancer (MFMCC) are the significant aspects that determine a specialist's choice between applying breast-conserving therapy (BCT) or performing a mastectomy. This study aimed to assess the usefulness of mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in women diagnosed with breast cancer before qualifying for surgical intervention to visualize other (additional) cancer foci.

METHODS

The study included 60 breast cancer cases out of 630 patients initially who underwent surgery due to breast cancer from January 2015 to April 2019. MG, CESM, and MRI were compared with each other in terms of the presence of MFMCC and assessed for compliance with the postoperative histopathological examination (HP).

RESULTS

Histopathological examination confirmed the presence of MFMCC in 33/60 (55%) patients. The sensitivity of MG in detecting MFMCC was 50%, and its specificity was 95.83%. For CESM, the sensitivity was 85.29%, and the specificity was 96.15%. For MRI, all the above-mentioned parameters were higher as follows: sensitivity-91.18%; specificity-92.31%.

CONCLUSIONS

In patients with MFMCC, both CESM and MRI are highly sensitive in the detection of additional cancer foci. Both CESM and MRI change the extent of surgical intervention in every fourth patient.

Association of Local Therapy With Quality-of-Life Outcomes in Young Women With Breast Cancer

Importance

Increasing rates of bilateral mastectomy have been most pronounced in young women with breast cancer, but the association of surgery with long-term quality of life (QOL) remains largely unknown.

Objective

To examine the association of surgery with longer-term satisfaction and QOL in young breast cancer survivors.

Design, Setting, and Participants

This multicenter cross-sectional study of a prospective cohort was conducted from October 2016 to November 2017, at academic and community hospitals in North America. Women 40 years or younger enrolled in the Young Women's Breast Cancer Study were assessed. Data analysis was performed from during a 1- to 2-year period after conclusion of the study.

Exposures

Primary breast surgery, reconstruction, and radiotherapy.

Main Outcomes and Measures

Mean BREAST-Q breast satisfaction and physical, psychosocial, and sexual well-being scores were compared by type of surgery; higher BREAST-Q scores (range, 0-100) indicate better QOL. Linear regression was used to identify demographic and clinical factors associated with BREAST-Q scores for each domain.

Results

A total of 560 women with stage 0 to III breast cancer (median age at diagnosis, 36 years; range, 17-40 years; 484 [86%] with stage 0-II disease) completed the BREAST-Q a median of 5.8 years (range, 1.9-10.4 years) from diagnosis. A total of 290 patients (52%) of patients underwent bilateral mastectomy, 110 patients (20%) underwent unilateral mastectomy, and 160 patients (28%) received breast-conserving therapy. Among mastectomy patients, 357 (89%) had reconstruction and 181 (45%) received radiotherapy. In multivariate analyses, implant-based reconstruction (vs autologous) was associated with decreased breast satisfaction (β = -7.4; 95% CI, -12.8 to -2.1; P = .007) and complex reconstruction (vs autologous) with worse physical well-being (β = -14.0; 95% CI, -22.2 to -5.7; P < .001).

Conclusions and Relevance

These results suggest that local therapy in young breast cancer survivors is persistently associated with poorer scores in multiple QOL domains, particularly among those treated with mastectomy and radiotherapy, irrespective of breast reconstruction. Socioeconomic stressors also appear to play a role.

Trend and survival benefit of contralateral prophylactic mastectomy among men with stage I-III unilateral breast cancer in the USA, 1998-2016

PURPOSE

Our study aimed to explore temporal trends and survival benefit of contralateral prophylactic mastectomy (CPM) in male breast cancer (MBC).

METHODS

Men with stage I-III unilateral breast cancer between 1998 and 2016 were identified from the surveillance, epidemiology, and end results (SEER). We compared CPM rate over the study period using the Cochrane-Armitage test for trend. Logistic regression model was used to test for factors predicting CPM. Survival analysis was conducted in patients who underwent CPM or unilateral mastectomy (UM) with a first diagnosis of unilateral breast cancer. Kaplan-Meier curve and univariate and multivariable Cox proportional hazards regression analyses were performed to compare overall survival (OS) and breast cancer-specific survival (BCSS) between CPM and UM groups. Propensity score matching was adopted to balance baseline characteristics.

RESULTS

5118 MBC cases were included in the present study, with 4.1% (n = 209) patients underwent CPM. The proportion of men undergoing CPM increased from 1.7 in 1998 to 6.3% in 2016 (P < 0.0001). Young age, recent years of diagnosis, higher tumor grade and lower T stage were significantly associated with CPM. A cohort of 3566 patients were enrolled in survival analysis with a median follow-up of 65 months. CPM was associated with better OS (HR 0.58, 95% CI 0.37-0.89, P = 0.022) rather than BCSS (HR 0.57, 95% CI 0.29-1.11, P = 0.153) compared with UM. In propensity score-matched model, CPM was not an independent prognostic factor for OS (HR 0.83, 95% CI 0.46-1.52, P = 0.553) and BCSS (HR 0.98, 95% CI 0.39-2.47, P = 0.970).

CONCLUSION

Our study revealed a dramatic increase in CPM utilization among MBC, especially in young patients. However, CPM provides no survival benefit for MBC compared with UM, indicating the decision of CPM should be fully discussed.

Improved Survival after Breast-Conserving Therapy Compared with Mastectomy in Stage I-IIA Breast Cancer

Simple Summary

The majority of patients with breast cancer are suitable for either breast-conserving therapy, consisting of breast-conserving surgery and radiation therapy, or mastectomy alone. In the present study, we compared survival outcomes in 1360 patients affected with early-stage breast cancer (stage I-IIA) according to the type of local treatment. We confirmed that patients treated with breast-conserving therapy had a lower rate of local, regional, and distant disease recurrences, and at least equivalent overall survival compared to those treated with mastectomy alone. Our results add to previous research showing a potential benefit of breast-conserving therapy when compared to mastectomy in patients suitable for both treatments at baseline.

Abstract

In the current study, we sought to compare survival outcomes after breast-conserving therapy (BCT) or mastectomy alone in patients with stage I-IIA breast cancer, whose tumors are typically suitable for both locoregional treatments. The study cohort consisted of 1360 patients with stage I-IIA (T1–2N0 or T0–1N1) breast cancer diagnosed between 2001 and 2013 and treated with either BCT (n = 1021, 75.1%) or mastectomy alone (n = 339, 24.9%). Median follow-ups for disease-free survival (DFS) and overall survival (OS) were 6.9 years (range, 0.3–15.9) and 7.5 years (range, 0.2–25.9), respectively. Fifteen (1.1%), 14 (1.0%) and 48 (3.5%) patients experienced local, regional, and distant relapse, respectively. For the whole cohort of patients, the estimated 5-year DFS and OS were 96% and 97%, respectively. After stratification based on the type of local treatment, the estimated 5-year DFS for BCT was 97%, while it was 91% (p < 0.001) for mastectomy-only treatment. Inverse probability of treatment weighting matching based on confounding confirmed that mastectomy was associated with worse DFS (HR 2.839, 95% CI 1.760–4.579, p < 0.0001), but not with OS (HR 1.455, 95% CI 0.844–2.511, p = 0.177). In our study, BCT was shown to have improved disease-specific outcomes compared to mastectomy alone, emphasizing the important role of adjuvant treatments, including postoperative radiation therapy, in patients with early-stage breast cancer at diagnosis.

The risk of contralateral breast cancer: a SEER-based analysis

BACKGROUND

We sought to estimate the annual risk and 25-year cumulative risk of contralateral breast cancer among women with stage 0-III unilateral breast cancer.

METHODS

We identified 812,851 women with unilateral breast cancer diagnosed between 1990 and 2015 in the SEER database and followed them for contralateral breast cancer for up to 25 years. Women with a known bilateral mastectomy were excluded. We calculated the annual risk of contralateral breast cancer by age at diagnosis, by time since diagnosis and by current age. We compared risks by ductal carcinoma in situ (DCIS) versus invasive disease, by race and by oestrogen receptor (ER) status of the first cancer.

RESULTS

There were 25,958 cases of contralateral invasive breast cancer diagnosed (3.2% of all patients). The annual risk of contralateral breast cancer over the 25-year follow-up period was 0.37% and the 25-year actuarial risk of contralateral invasive breast cancer was 9.9%. The annual risk varied to a small degree by age of diagnosis, by time elapsed since diagnosis and by current age. The 25-year actuarial risk was similar for DCIS and invasive breast cancer patients (10.1 versus 9.9%). The 25-year actuarial risk was higher for black women (12.7%) than for white women (9.7%) and was lower for women with ER-positive breast cancer (9.5%) than for women with ER-negative breast cancer (11.2%).

CONCLUSIONS

Women with unilateral breast cancer experience an annual risk of contralateral breast cancer ~0.4% per year, which persists over the 25-year follow-up period.

Influencers of the Decision to Undergo Contralateral Prophylactic Mastectomy among Women with Unilateral Breast Cancer

Simple Summary

In this survey study, we examined survey responses from 397 women with stage 0 to III unilateral breast cancer and found that partners, physicians, and the media were significant relative to the patient’s own influence in their decision to undergo a CPM. The findings of this study may inform policy by highlighting the need for educational aids, programs, or tools that help women with unilateral breast cancer make informed, evidence-based decisions regarding CPM efficacy.

Abstract

(1) Background: The relatively high rate of contralateral prophylactic mastectomy (CPM) among women with early stage unilateral breast cancer (BC) has raised concerns. We sought to assess the influence of partners, physicians, and the media on the decision of women with unilateral BC to undergo CPM and identify clinicopathological variables associated with the decision to undergo CPM. (2) Patients and Methods: Women with stage 0 to III unilateral BC who underwent CPM between January 2010 and December 2017. Patients were surveyed regarding factors influencing their self-determined decision to undergo CPM. Partner, physician, and media influence factors were modeled by logistic regressions with adjustments for a family history of breast cancer and pathological stage. (3) Results: 397 (29.6%) patients completed the survey and were included in the study. Partners, physicians, and the media significantly influenced patients’ decision to undergo CPM. The logistic regression models showed that, compared to self-determination alone, overall influence on the CPM decision was significantly higher for physicians (p = 0.0006) and significantly lower for partners and the media (p < 0.0001 for both). Fifty-nine percent of patients’ decisions were influenced by physicians, 28% were influenced by partners, and only 17% were influenced by the media. The model also showed that patients with a family history of BC had significantly higher odds of being influenced by a partner than did those without a family history of BC (p = 0.015). (4) Conclusions: Compared to self-determination, physicians had a greater influence and partners and the media had a lower influence on the decision of women with unilateral BC to undergo CPM. Strong family history was significantly associated with a patient’s decision to undergo CPM.

Arm Morbidity After Local Therapy for Young Breast Cancer Patients

BACKGROUND

The impact of patient demographics and local therapy choice on arm morbidity in young breast cancer patients is understudied despite its importance given the long survivorship period. This study assessed patient-reported arm morbidity in the Young Women's Breast Cancer Study (YWS), a prospective cohort study.

METHODS

From 2006 to 2016, 1302 women with breast cancer diagnosed at the age of 40 years or younger enrolled in the YWS. The participants regularly complete surveys. The response rates are higher than 86%. Using the Breast Cancer Prevention Trial Checklist, this study examined the prevalence of patient-reported postoperative arm swelling and decreased range of motion (ROM) 1 year after diagnosis, stratified by local therapy strategy, in patients who had surgery for stages 1 to 3 disease. Logistic regression analysis was used to identify risk factors for arm morbidity.

RESULTS

Among 888 eligible participants (median age, 37 years), 14% reported arm swelling and 34% reported decreased ROM at 1 year. Arm swelling was reported by 23.6% of the patients who had axillary lymph node dissection (ALND) and 24.6% of the patients who received ALND and post-mastectomy radiation therapy (PMRT). In the multivariable analysis, the patients who reported being financially uncomfortable or who had ALND were at higher risk of arm swelling at 1 year. Being overweight, receiving ALND after sentinel lymph node biopsy, and receiving PMRT were associated with decreased ROM at 1 year.

CONCLUSION

High rates of self-reported arm morbidity in young breast cancer survivors were reported, particularly in patients receiving ALND and PMRT. Attention to the risks and benefits of differing local therapy strategies for ALND and PMRT patients is warranted.

Longitudinal Study of Psychosocial Outcomes Following Surgery in Women with Unilateral Nonhereditary Breast Cancer

INTRODUCTION

Rates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery.

PATIENTS AND METHODS

We performed a prospective cohort study of women with unilateral, sporadic stage 0-III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant.

RESULTS

A total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001).

CONCLUSIONS

Psychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Impact of age, rurality and distance in predicting contralateral prophylactic mastectomy for breast cancer in a Midwestern state: a population-based study

PURPOSE

Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns.

METHODS

Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression.

RESULTS

22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86).

CONCLUSION

There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.

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.

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.

•

Contralateral prophylactic mastectomy rates have increased over the last 20 years.

•

Patients may want CPM to reduce risk of contralateral breast cancer and mortality.

•

Patients do not always have the tools available to make a well-informed decision.

•

Patient and surgeon’s shared decision-making could optimize the use of CPM.

Association of Breast Cancer Surgery With Quality of Life and Psychosocial Well-being in Young Breast Cancer Survivors

Importance

Young women with breast cancer are increasingly choosing bilateral mastectomy (BM), yet little is known about short-term and long-term physical and psychosocial well-being following surgery in this population.

Objective

To evaluate the differential associations of surgery with quality of life (QOL) and psychosocial outcomes from 1 to 5 years following diagnosis.

Design, Setting, and Participants

Cohort study.

Setting

Multicenter, including academic and community hospitals in North America.

Participants

Women age ≤40 when diagnosed with Stage 0-3 with unilateral breast cancer between 2006 and 2016 who had surgery and completed QOL and psychosocial assessments.

Exposures (for observational studies)

Primary breast surgery including breast-conserving surgery (BCS), unilateral mastectomy (UM), and BM.

Main Outcomes and Measures

Physical functioning, body image, sexual health, anxiety and depressive symptoms were assessed in follow-up.

Results

Of 826 women, mean age at diagnosis was 36.1 years; most women were White non-Hispanic (86.7%). Regarding surgery, 45% had BM, 31% BCS, and 24% UM. Of women who had BM/UM, 84% had reconstruction. While physical functioning, sexuality, and body image improved over time, sexuality and body image were consistently worse (higher adjusted mean scores) among women who had BM vs BCS (body image: year 1, 1.32 vs 0.64; P < .001; year 5, 1.19 vs 0.48; P < .001; sexuality: year 1, 1.66 vs 1.20, P < .001; year 5, 1.43 vs 0.96; P < .001) or UM (body image: year 1, 1.32 vs 1.15; P = .06; year 5, 1.19 vs 0.96; P = .02; sexuality: year 1, 1.66 vs 1.41; P = .02; year 5, 1.43 vs 1.09; P = .002). Anxiety improved across groups, but adjusted mean scores remained higher among women who had BM vs BCS/UM at 1 year (BM, 7.75 vs BCS, 6.94; P = .005; BM, 7.75 vs UM, 6.58; P = .005), 2 years (BM, 7.47 vs BCS, 6.18; P < .001; BM, 7.47 vs UM, 6.07; P < .001) and 5 years (BM, 6.67 vs BCS, 5.91; P = .05; BM, 6.67 vs UM, 5.79; P = .05). There were minimal between-group differences in depression levels in follow-up.

Conclusions and Relevance

While QOL improves over time, young breast cancer survivors who undergo more extensive surgery have worse body image, sexual health, and anxiety compared with women undergoing less extensive surgery. Ensuring young women are aware of the short-term and long-term effects of surgery and receive support when making surgical decisions is warranted.

Canada follows the US in the rise of bilateral mastectomies for unilateral breast cancer: a 23-year population cohort study

INTRODUCTION

The use of contralateral prophylactic mastectomy (CPM) continues to grow despite the absence of evidence supporting a survival benefit. This study's objectives were to (1) describe the trends in the rates of unilateral and bilateral mastectomy (BM) in women diagnosed with unilateral breast cancer (UBC) in Ontario, Canada from 1991 to 2013, and (2) identify factors associated with BM to treat UBC.

METHODS

This retrospective cohort analysis included all women aged 18 and older diagnosed with UBC between January 1991 and December 2013. Health administrative data from the Institute for Clinical Evaluative Sciences, the Ontario Cancer Registry, and the Discharge Abstract Database were used to identify all breast cancer and mastectomy cases. Age-adjusted mastectomy rates were plotted over time. Univariable and multivariable analyses included clinically significant covariates.

RESULTS

From 1991 to 2013 there were 172,165 cases of UBC and 64,886 mastectomies (37.7%) performed in Ontario. 13.6% of the mastectomies were bilateral. BM rates increased over sixfold (from 4 to 25%) across all age groups under age 70 over a 23-year period. On multivariable analysis, younger age, higher income, rural community, earlier breast cancer stage, lobular histology, availability of reconstruction and teaching hospitals were associated with increased odds of BM.

CONCLUSIONS

This is the largest population study of breast cancer patients in Canada and shows an increasing rate of BM for UBC. The results are similar to those already described in the US and highlight the importance of continued efforts to promote efficient communication and evidence-based decision-making prior to breast surgery.

Patient-reported outcomes among women with unilateral breast cancer undergoing breast conservation versus single or double mastectomy

PURPOSE

More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer.

METHODS

We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15 months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal-Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point.

RESULTS

203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15 months, it was significantly lower in BM patients than in BCT patients. Women who felt "very" confident and "very" informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15 months.

CONCLUSION

While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.

Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery

Importance

Overtreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer.

Objective

To evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation.

Evidence Review

A systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use.

Findings

Concordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes.

Conclusions and Relevance

This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.

Discussions about contralateral prophylactic mastectomy among surgical oncology providers and women with sporadic breast cancer: a content analysis

Rates of contralateral prophylactic mastectomy (CPM) have risen substantially, yet little is known about how and to what extent CPM is discussed within surgical oncology visits at the time of treatment decision-making. We examined CPM discussions in naturally occurring interactions between sporadic breast cancer patients and their surgical oncology providers. Women with early-stage unilateral disease were recruited before their first surgical visit and completed brief questionnaires to determine study eligibility and interest in treatment options. After their visits, enrolled patients and their providers completed questionnaires assessing discussion of and interest in CPM. Audio-recorded visits from 36 unique patients were randomly selected, transcribed, and analyzed. A CPM discussion was present in 28 transcripts. Approximately half of CPM discussions were initiated by the patient or the oncology provider. The topic of CPM was most frequently introduced while reviewing available treatment options. Patients were most interested in pursuing CPM to reduce the risk of future breast cancer. Providers most frequently responded by offering information (e.g., about risk of contralateral disease). A high level of agreement was found among patient, provider, and observer ratings of whether or not CPM was discussed. CPM discussions were consistently present within our sample. Results can be used to build providers' skills and bring provider-patient communication more in line with best practices and recommendations from leading professional medical societies.

Predictors of genetic testing uptake in newly diagnosed breast cancer patients

BACKGROUND AND OBJECTIVES

Many newly diagnosed breast cancer patients do not receive genetic counseling and testing at the time of diagnosis. We examined predictors of genetic testing (GT) in this population.

METHODS

Within a randomized controlled trial of proactive rapid genetic counseling and testing vs usual care, patients completed a baseline survey within 6 weeks of breast cancer diagnosis but before a definitive survey. We conducted a multinomial logistic regression to identify predictors of GT timing/uptake.

RESULTS

Having discussed GT with a surgeon was a dominant predictor (χ² (2, N = 320) = 70.13; P < .0001). Among those who discussed GT with a surgeon, patients who had made a final surgery decision were less likely to receive GT before surgery compared with postsurgically (OR [odds ratio] = 0.24; 95% confidence interval [CI] = 0.12-0.49) or no testing (OR = 0.28; 95% CI = 0.14-0.56). Older patients (OR = 0.95; 95% CI = 0.91-0.99) and participants enrolled in New York/New Jersey (OR = 0.22; 95% CI = 0.07-0.72) were less likely to be tested compared with receiving results before surgery. Those with higher perceived risk (OR = 1.02; 95% CI = 1.00-1.03) were more likely to receive results before surgery than to not be tested.

CONCLUSIONS

This study highlights the role of patient-physician communication about GT as well as patient-level factors that predict presurgical GT.

Contralateral prophylactic mastectomy in breast cancer: what to discuss with patients

Introduction: The contralateral prophylactic mastectomy (CPM) rate in the U.S. has been steadily increasing. This is of particular concern because many women who undergo this procedure are candidates for breast-conserving surgery.Areas covered: CPM's medical benefit is related to the risk of contralateral cancer development and whether CPM provides a survival benefit. Contralateral cancer rates have decreased, and CPM does not provide a survival benefit. Other potential benefits of the procedure may be improved quality of life; these data are reviewed. Research efforts have been undertaken to better understand the decision-making process of patients who consider, and ultimately undergo, this procedure.Expert opinion: Decisional traits, personal values, the desire for peace of mind, and the desire to obtain breast symmetry are important factors that drive a woman's decision to undergo CPM. Additionally, many patients lack the knowledge on how different types of breast surgery impact outcomes. To improve the shared decision-making process, a stepwise approach to address possible misconceptions, and clarify the real risks/benefits of this procedure should be utilized. A clear recommendation (for/against) should be made for every patient with newly diagnosed breast cancer who considers CPM. Communication tools to assist patients and surgeons in this process are sorely needed.