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Surgical Outcome Measures in a Cohort of Patients at High Risk of Breast Cancer Treated by Bilateral Risk Reducing Mastectomy and Breast Reconstruction. Plast Reconstr Surg 2022; 150:496e-505e. [PMID: 35749222 DOI: 10.1097/prs.0000000000009383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Women with breast cancer related genetic pathogenic variants (e.g. BRCA1, BRCA2) or with a strong family history carry lifetime risks of developing breast cancer of up to 80-90%. A significant proportion of these women proceed to bilateral risk reducing mastectomy (RRM). We aimed to document the surgical morbidity of RRM and establish whether a diagnosis of breast cancer at the time of surgery impacted on outcomes. METHODS Clinical details of 445 women identified as having >25% lifetime risk of developing breast cancer who underwent RRM and breast reconstruction were interrogated for surgical outcomes such as planned, unplanned and emergency procedures, complication rates, length of stay and longevity of breast reconstruction. These outcome measures were recorded in women diagnosed with breast cancer perioperatively (cancer group, CG) and those without malignancy (benign group, BG). RESULTS Median follow up was similar in both groups (BG, 70months; CG 73 months). Patients were older in the CG than BG (43y v 39y; p<0.001). Women in the CG required more planned procedures to complete reconstruction than those in the BG (4 v 2; p=0.002). Emergency procedures, unplanned surgical interventions (e.g. capsulectomy) and post reconstruction complication rates were similar between groups.One in five women overall required revisional surgery. Patients with autologous reconstructions had a revision rate of 1.24/1000 person years compared with 2.52 in the implant reconstruction group. CONCLUSION Women contemplating RRM can be reassured that this a safe and effective procedure but will likely take multiple interventions. This knowledge should be integral to obtaining informed consent.
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Patzelt M, Zarubova L, Vecerova M, Barta J, Ouzky M, Sukop A. Risk Comparison Using Autologous Dermal Flap and Absorbable Breast Mesh on Patient Undergoing Subcutaneous Mastectomy with Immediate Breast Reconstruction. Aesthetic Plast Surg 2022; 46:1145-1152. [PMID: 35165758 DOI: 10.1007/s00266-022-02799-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/17/2022] [Indexed: 11/01/2022]
Abstract
In patients with large breasts undergoing a subcutaneous mastectomy with immediate implant-based reconstruction, is necessary to perform a mastopexy. The combination of these procedures increases the complication rate. To reduce it, it is necessary to cover the lower pole of the implant. Our study aimed to compare the use of an autologous dermal flap and an absorbable breast mesh. A total of 64 patients without previous breast surgery were divided into 2 groups, each with 32 patients. In the 1st group, the implant was covered with an autologous caudally based dermal flap, sutured to the great pectoral muscle. In the 2nd group, the implant was covered with a fully absorbable breast mesh, fixed caudally in the inframammary fold and cranially to the great pectoral muscle. The incidence of complications, the aesthetic effect, and patient satisfaction were evaluated in a one-year follow-up. In the 1st group, there were 2 cases of seroma, 2 partial nipple-areola complex necrosis, 4 cases of dehiscence in the T-suture, and the malposition of the implant in 2 patients. In the 2nd group, there were 2 cases of seroma, 2 cases of T-junction dehiscence, and 1 case of full nipple-areola complex necrosis, which resulted in implant loss. There was no significant difference in patient satisfaction between the study groups. The dermal flap is more suitable for breasts with pronounced ptosis. The use of the synthetic mesh is suitable for smaller breasts, where the possible dermal flap would be too small to cover the implant. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Gandhi A, Duxbury P, Murphy J, Foden P, Lalloo F, Clancy T, Wisely J, Kirwan CC, Howell A, Evans DG. Patient reported outcome measures in a cohort of patients at high risk of breast cancer treated by bilateral risk reducing mastectomy and breast reconstruction. J Plast Reconstr Aesthet Surg 2021; 75:69-76. [PMID: 34219040 DOI: 10.1016/j.bjps.2021.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/12/2021] [Accepted: 06/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many women with increased lifetime risk of developing breast cancer, due to pathogenic gene variants or family history, choose to undergo bilateral risk reducing mastectomies (BRRM). Patient reported outcome measures (PROMS) are an increasingly important part of informed consent but are little studied in women undergoing BRRM. METHODS We used a validated PROMS tool for breast reconstruction (BREAST-Q) in 297 women who had BRRM and breast reconstruction, 81% of whom had no malignancy (Benign Group, BG) and 19% in whom a perioperative breast cancer was diagnosed (Cancer Group, CG). 128 women also completed a Hospital Anxiety & Depression Score (HADS) questionnaire to test if preoperative HADS score could predict PROMS outcomes. RESULTS Women in the CG had lower PROMS scores for satisfaction with their breasts, nipple reconstruction and sexual wellbeing. Both groups reported equal satisfaction with BRRM outcome and psychosocial well-being. Physical well-being PROMS of the abdomen and chest were high in women in both groups as were scores for satisfaction with the care they received. The CG group reported suboptimal quality of patient information. A higher presurgical HADS anxiety score predicted less favourable postoperative psychosocial well-being despite similar levels of satisfaction with aesthetic outcome. CONCLUSION We show a high degree of patient reported satisfaction by woman undergoing BRRM and reconstruction. There was a negative association with a cancer diagnosis on quality of life PROMS and higher preoperative anxiety levels negatively affected postoperative psychosocial well-being. These important findings should be part of the informed consent process during preoperative counselling.
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Affiliation(s)
- A Gandhi
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - P Duxbury
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - J Murphy
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - P Foden
- Department of Medical Statistics, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - F Lalloo
- Department of Clinical Genetics, Manchester Centre for Genomic Medicine, St Marys Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - T Clancy
- Department of Clinical Genetics, Manchester Centre for Genomic Medicine, St Marys Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - J Wisely
- Department of Clinical Psychology, Laureate House, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - C C Kirwan
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - A Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - D G Evans
- Prevent Breast Cancer Centre, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK; Division of Evolution and Genomic Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Marcinkute R, Woodward ER, Gandhi A, Howell S, Crosbie EJ, Wissely J, Harvey J, Highton L, Murphy J, Holland C, Edmondson R, Clayton R, Barr L, Harkness EF, Howell A, Lalloo F, Evans DG. Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers. J Med Genet 2021; 59:133-140. [PMID: 33568438 DOI: 10.1136/jmedgenet-2020-107356] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Women testing positive for BRCA1/2 pathogenic variants have high lifetime risks of breast cancer (BC) and ovarian cancer. The effectiveness of risk reducing surgery (RRS) has been demonstrated in numerous previous studies. We evaluated long-term uptake, timing and effectiveness of risk reducing mastectomy (RRM) and bilateral salpingo-oophorectomy (RRSO) in healthy BRCA1/2 carriers. METHODS Women were prospectively followed up from positive genetic test (GT) result to censor date. χ² testing compared categorical variables; Cox regression model estimated HRs and 95% CI for BC/ovarian cancer cases associated with RRS, and impact on all-cause mortality; Kaplan-Meier curves estimated cumulative RRS uptake. The annual cancer incidence was estimated by women-years at risk. RESULTS In total, 887 women were included in this analysis. Mean follow-up was 6.26 years (range=0.01-24.3; total=4685.4 women-years). RRS was performed in 512 women, 73 before GT. Overall RRM uptake was 57.9% and RRSO uptake was 78.6%. The median time from GT to RRM was 18.4 months, and from GT to RRSO-10.0 months. Annual BC incidence in the study population was 1.28%. Relative BC risk reduction (RRM versus non-RRM) was 94%. Risk reduction of ovarian cancer (RRSO versus non-RRSO) was 100%. CONCLUSION Over a 24-year period, we observed an increasing number of women opting for RRS. We showed that the timing of RRS remains suboptimal, especially in women undergoing RRSO. Both RRM and RRSO showed a significant effect on relevant cancer risk reduction. However, there was no statistically significant RRSO protective effect on BC.
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Affiliation(s)
- Ruta Marcinkute
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Emma Roisin Woodward
- Manchester Centre for Genomic Medicine, Central Manchester NHS Foundation Trust, Manchester, UK.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ashu Gandhi
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Sacha Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, St Mary's Hospital, University of Manchester, Manchester, UK.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Julie Wissely
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - James Harvey
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Lindsay Highton
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - John Murphy
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Cathrine Holland
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard Edmondson
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, St Mary's Hospital, University of Manchester, Manchester, UK.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard Clayton
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Lester Barr
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Elaine F Harkness
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK
| | - Fiona Lalloo
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester NHS Foundation Trust, Manchester, UK .,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Basu NN, Hodson J, Chatterjee S, Gandhi A, Wisely J, Harvey J, Highton L, Murphy J, Barnes N, Johnson R, Barr L, Kirwan CC, Howell S, Baildam AD, Howell A, Evans DG. The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer. Sci Rep 2021; 11:2847. [PMID: 33531640 PMCID: PMC7854742 DOI: 10.1038/s41598-021-82654-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
Contralateral risk-reducing mastectomy (CRRM) rates have tripled over the last 2 decades. Reasons for this are multi-factorial, with those harbouring a pathogenic variant in the BRCA1/2 gene having the greatest survival benefit. On May 14th, 2013, Angelina Jolie shared the news of her bilateral risk-reducing mastectomy (BRRM), on the basis of her BRCA1 pathogenic variant status. We evaluated the impact of this news on rates of CRRM in women with increased risk for developing breast cancer after being diagnosed with unilateral breast cancer. The prospective cohort study included all women with at least a moderate lifetime risk of developing breast cancer who attended our family history clinic (1987–2019) and were subsequently diagnosed with unilateral breast cancer. Rates of CRRM were then compared between patients diagnosed with breast cancer before and after Angelina Jolie’s announcement (pre- vs. post-AJ). Of 386 breast cancer patients, with a mean age at diagnosis of 48 ± 8 years, 268 (69.4%) were diagnosed in the pre-AJ period, and 118 (30.6%) in the post-AJ period. Of these, 123 (31.9%) underwent CRRM, a median 42 (interquartile range: 11–54) days after the index cancer surgery. Rates of CRRM doubled following AJ’s news, from 23.9% pre-AJ to 50.0% post AJ (p < 0.001). Rates of CRRM were found to decrease with increasing age at breast cancer (p < 0.001) and tumour TNM stage (p = 0.040), and to increase with the estimated lifetime risk of breast cancer (p < 0.001) and tumour grade (p = 0.015) on univariable analysis. After adjusting for these factors, the step-change increase in CRRM rates post-AJ remained significant (odds ratio: 9.61, p < 0.001). The AJ effect appears to have been associated with higher rates of CRRM amongst breast cancer patients with increased cancer risk. CRRM rates were highest amongst younger women and those with the highest lifetime risk profile. Clinicians need to be aware of how media news can impact on the delivery of cancer related services. Communicating objective assessment of risk is important when counselling women on the merits of risk-reducing surgery.
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Affiliation(s)
- Narendra Nath Basu
- University of Birmingham, Birmingham, B15 2TT, UK. .,University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham, B15 2TH, UK.
| | - James Hodson
- University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Shaunak Chatterjee
- University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Ashu Gandhi
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Julie Wisely
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - James Harvey
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Lyndsey Highton
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - John Murphy
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Nicola Barnes
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Richard Johnson
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Lester Barr
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Cliona C Kirwan
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Sacha Howell
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, M20, UK
| | - Andrew D Baildam
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - Anthony Howell
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, M20, UK
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, M20, UK.,NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Clinical Genetics Service, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK
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Long-Term Evaluation of Women Referred to a Breast Cancer Family History Clinic (Manchester UK 1987-2020). Cancers (Basel) 2020; 12:cancers12123697. [PMID: 33317064 PMCID: PMC7763143 DOI: 10.3390/cancers12123697] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
Simple Summary This study reports the management of women at high risk for breast cancer over a 33 years period. The aim was to summarize the numbers seen and to report the results of our studies on gene testing, the outcomes of screening and the success of preventive methods including lifestyle change, chemoprevention and risk-reducing mastectomy. We also discuss how the clinical Family History Service may be improved in the future. Abstract Clinics for women concerned about their family history of breast cancer are widely established. A Family History Clinic was set-up in Manchester, UK, in 1987 in a Breast Unit serving a population of 1.8 million. In this review, we report the outcome of risk assessment, screening and prevention strategies in the clinic and propose future approaches. Between 1987–2020, 14,311 women were referred, of whom 6.4% were from known gene families, 38.2% were at high risk (≥30% lifetime risk), 37.7% at moderate risk (17–29%), and 17.7% at an average/population risk who were discharged. A total of 4168 (29.1%) women were eligible for genetic testing and 736 carried pathogenic variants, predominantly in BRCA1 and BRCA2 but also other genes (5.1% of direct referrals). All women at high or moderate risk were offered annual mammographic screening between ages 30 and 40 years old: 646 cancers were detected in women at high and moderate risk (5.5%) with a detection rate of 5 per 1000 screens. Incident breast cancers were largely of good prognosis and resulted in a predicted survival advantage. All high/moderate-risk women were offered lifestyle prevention advice and 14–27% entered various lifestyle studies. From 1992–2003, women were offered entry into IBIS-I (tamoxifen) and IBIS-II (anastrozole) trials (12.5% of invitees joined). The NICE guidelines ratified the use of tamoxifen and raloxifene (2013) and subsequently anastrozole (2017) for prevention; 10.8% women took up the offer of such treatment between 2013–2020. Since 1994, 7164 eligible women at ≥25% lifetime risk of breast cancer were offered a discussion of risk-reducing breast surgery and 451 (6.2%) had surgery. New approaches in all aspects of the service are needed to build on these results.
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Baildam AD. Current knowledge of risk reducing mastectomy: Indications, techniques, results, benefits, harms. Breast 2019; 46:48-51. [PMID: 31082761 DOI: 10.1016/j.breast.2019.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022] Open
Abstract
The last twenty years have seen a complete change in society's attitude to the strategy of risk reduction of breast cancer in high-risk individuals by means of proactive mastectomy. Once termed 'prophylactic mastectomy', risk reducing mastectomy (RRM) was considered two decades ago not only extreme, but in some quarters almost unethical. RRM is now commonly undertaken in specialist breast units for women at high individual breast cancer risk, by virtue of an inherited breast cancer related gene mutation or from calculated high statistical risk from family history data, and the efficacy of RRM in reducing subsequent incident diagnoses of breast cancer has been published from a number of centres. RRM is offered routinely in conjunction with total breast reconstruction, using the whole range of reconstructive surgical techniques. The public announcement by the actor Angelina Jolie in 2013 that she had inherited and harboured a BRCA1 gene mutation, and was undergoing RRM and breast reconstruction to lower her intrinsic breast cancer risk, had a significant effect on public attitudes and perception. Whilst there are other means of lowering breast cancer risk by means of selective oestrogen receptor modulators, such as tamoxifen and raloxifene, their lowering effect on risk of breast cancer remains substantially less than that afforded by surgical removal of 'at risk' breast tissue. The progressive development and increasing sophistication of techniques of breast reconstructive surgery has paralleled the trend for more RRM surgery, and the substantial majority of women who opt for RRM choose immediate breast reconstruction.
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Affiliation(s)
- Andrew D Baildam
- Consultant Oncoplastic Breast Surgeon, King Edward VII's Hospital London, UK.
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8
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Glassey R, O'Connor M, Ives A, Saunders C, kConFab Investigators, O'Sullivan S, Hardcastle SJ. Patients' perspectives and experiences concerning barriers to accessing information about bilateral prophylactic mastectomy. Breast 2018; 40:116-122. [PMID: 29758504 DOI: 10.1016/j.breast.2018.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 04/17/2018] [Accepted: 05/07/2018] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To explore the barriers and experiences of accessing information for women who have received genetic risk assessment/testing results for breast cancer (BC) and are considering a bilateral prophylactic mastectomy (BPM) and, exploring participants' preferences concerning information and support needs. METHODS A qualitative retrospective study guided by interpretative phenomenological analysis was utilised. Semi-structured interviews were conducted with forty-six women who were either considering BPM or had already undergone the surgery. RESULTS Three themes identified barriers to accessing information; difficulties accessing information, inconsistent information and clinical focus/medicalized information. A fourth theme - preferences of information and support needs, identified three subthemes; these were, psychological support, clearly defined processes and photos of mastectomies/reconstruction surgeries. CONCLUSIONS Barriers to accessing information appeared to be widespread. A lack of integrated services contributed to inconsistent information, and medicalized terminology/clinical focus of consultations further complicated understanding. Preferences for information include clearly defined processes, so women know the pathways after confirmation of familial BC risk. Clinical implications include a multidisciplinary team approach, and a protocol that reflects current practice.
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Affiliation(s)
- Rachael Glassey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.
| | - Moira O'Connor
- School of Psychology and Speech Pathology, Curtin University, Perth, Australia
| | - Angela Ives
- CaPCREU, Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Christobel Saunders
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - kConFab Investigators
- KConFab, Research Department, Peter MacCallum Cancer Centre, Melbourne, Australia; The Sir Peter MacCallum Department of Oncology University of Melbourne, Parkville, Australia
| | | | - Sarah J Hardcastle
- School of Psychology and Speech Pathology, Curtin University, Perth, Australia
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9
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Glassey R, Hardcastle SJ, O'Connor M, Ives A, Saunders C. Perceived influence of psychological consultation on psychological well-being, body image, and intimacy following bilateral prophylactic mastectomy: A qualitative analysis. Psychooncology 2017; 27:633-639. [PMID: 28945295 DOI: 10.1002/pon.4558] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study explored whether psychological consultation offered to women prior to bilateral prophylactic mastectomy (BPM) appeared to provide psychosocial benefit to younger women (<35 years) at high risk of developing breast cancer due to a mutation or family history. METHODS Qualitative interviews guided by interpretative phenomenological analysis were conducted retrospectively with 26 women who had undergone BPM. Participants were recruited from New Zealand and Australia, via a genetics clinic, registry, research cohort, and online. RESULTS Three themes were identified: psychological well-being and adjustment, satisfaction with intimacy, and body image. Participants that had seen a psychologist reported being more prepared for BPM and appeared to adjust positively post-surgery. They appeared to have improved psychological well-being, reported satisfaction with intimacy, and a more positive body image, compared with those who had no support. CONCLUSIONS Women who undergo psychological consultation prior to BPM appear to adjust positively after surgery. Implications for practice include standard psychological consultation for younger women (>35 years) considering BPM.
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Affiliation(s)
- Rachael Glassey
- Medical School, The University of Western Australia, Perth, Australia
| | - Sarah J Hardcastle
- Health Psychology and Behavioural Medicine Research Group, School of Psychology, Curtin University, Perth, Australia
| | - Moira O'Connor
- Health Psychology and Behavioural Medicine Research Group, School of Psychology, Curtin University, Perth, Australia
| | - Angela Ives
- Medical School, The University of Western Australia, Perth, Australia
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- kConFab, Research Department, Peter MacCallum Cancer Center, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology University of Melbourne, Parkville, Australia
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Perspectives of Women Considering Bilateral Prophylactic Mastectomy and their Peers towards a Telephone-Based Peer Support Intervention. J Genet Couns 2017; 27:274-288. [PMID: 28916957 DOI: 10.1007/s10897-017-0148-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/16/2017] [Indexed: 01/26/2023]
Abstract
Prophylactic mastectomy is an effective strategy to reduce the risk of breast cancer for women carrying a BRCA1/2 germline mutation. This decision is complex and may raise various concerns. Women considering this surgery have reported their desire to discuss the implications of this procedure with women who have undergone prophylactic mastectomy. We conducted a qualitative study to describe the topics covered during a telephone-based peer support intervention between women considering prophylactic mastectomy (recipients) and women who had undergone this surgery (peers), and to explore their perspectives regarding the intervention. Thirteen dyads were formed and data from participant logbooks and evaluation questionnaires were analyzed using a thematic content analysis. Three main dimensions emerged: physical, psychological, and social. The most frequent topics discussed were: surgery (92%), recovery (77%), pain and physical comfort (69%), impacts on intimacy and sexuality (54%), cancer-related anxiety (54%), experience related to loss of breasts (46%). Peers and recipients report that sharing experiences and thoughts about prophylactic mastectomy and the sense of mutual support within the dyad contributed significantly to their satisfaction. Special attention should be paid to the similarities between personal and medical profiles in order to create harmonious matches.
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11
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Basu NN, Ross GL, Evans DG, Barr L. The Manchester guidelines for contralateral risk-reducing mastectomy. World J Surg Oncol 2015; 13:237. [PMID: 26245209 PMCID: PMC4527227 DOI: 10.1186/s12957-015-0638-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/30/2015] [Indexed: 01/02/2023] Open
Abstract
Background Rates of contralateral risk-reducing mastectomy (CRRM) are rising, despite a decreasing global incidence of contralateral breast cancer. Reasons for requesting this procedure are complex, and we have previously shown a variable practice amongst breast and plastic surgeons in England. We propose a protocol, based on a published systematic review, a national UK survey and the Manchester experience of CRRM. Methods We reviewed the literature for risk factors for contralateral breast cancer and have devised a 5-step process that includes history taking, calculating contralateral breast cancer risk, cooling off period/counselling, multi-disciplinary assessment and consent. Members of the multi-disciplinary team included the breast surgeon, plastic surgeon and geneticist, who formulated guidelines. Results A simple formula to calculate the life-time risk of contralateral breast cancer has been devised. This allows stratification of breast cancer patients into different risk-groups: low, above average, moderate and high risk. Recommendations vary according to different risk groups. Conclusion These guidelines are a useful tool for clinicians counselling women requesting CRRM. Risk assessment is mandatory in this group of patients, and our formula allows evidence-based recommendations to be made.
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Affiliation(s)
- Narendra Nath Basu
- Nightingale and Genesis Prevention Centre, University Hospital South Manchester, Southmoor Road, Manchester, M23 9LT, UK. .,Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
| | - G L Ross
- The Institute of Cancer Sciences, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - D G Evans
- Nightingale and Genesis Prevention Centre, University Hospital South Manchester, Southmoor Road, Manchester, M23 9LT, UK.,St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - L Barr
- Nightingale and Genesis Prevention Centre, University Hospital South Manchester, Southmoor Road, Manchester, M23 9LT, UK
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12
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Leff DR, Ho C, Thomas H, Daniels R, Side L, Lambert F, Knight J, Griffiths M, Banwell M, Aitken J, Clayton G, Dua S, Shaw A, Smith S, Ramakrishnan V. A multidisciplinary team approach minimises prophylactic mastectomy rates. Eur J Surg Oncol 2015; 41:1005-12. [PMID: 25986853 DOI: 10.1016/j.ejso.2015.02.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/22/2015] [Accepted: 02/12/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making. METHODS We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded. RESULTS Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%). DISCUSSION MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.
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Affiliation(s)
- D R Leff
- The Breast Unit, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - C Ho
- The Breast Unit, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - H Thomas
- The Breast Unit, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - R Daniels
- The Breast Unit, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - L Side
- Institute for Women's Health, University College Hospitals, London, United Kingdom
| | - F Lambert
- Psychological Therapies Department, Mid Essex Hospitals Services NHS Trust, Essex, United Kingdom
| | - J Knight
- Breast Reconstruction Awareness Group, United Kingdom
| | - M Griffiths
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom
| | - M Banwell
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom
| | - J Aitken
- West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, United Kingdom
| | - G Clayton
- The Breast Unit, Mid Essex Hospitals NHS Trust, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - S Dua
- The Breast Unit, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - A Shaw
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom
| | - S Smith
- The Breast Unit, Broomfield Hospital, Chelmsford, Essex, United Kingdom
| | - V Ramakrishnan
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom.
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13
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Irwin G, Black A, Refsum S, McIntosh S. Skin-reducing mastectomy and one-stage implant reconstruction with a myodermal flap: A safe and effective technique in risk-reducing and therapeutic mastectomy. J Plast Reconstr Aesthet Surg 2013; 66:1188-94. [DOI: 10.1016/j.bjps.2013.04.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 10/26/2022]
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14
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One stage breast reconstruction following prophylactic mastectomy for ptotic breasts: The inferior dermal flap and implant. J Plast Reconstr Aesthet Surg 2012; 65:1204-8. [DOI: 10.1016/j.bjps.2012.03.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 03/10/2012] [Accepted: 03/26/2012] [Indexed: 11/19/2022]
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15
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Ross G. Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial flap with the Becker 35 expandable implant. J Plast Reconstr Aesthet Surg 2012; 65:705-10. [DOI: 10.1016/j.bjps.2011.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 11/24/2011] [Accepted: 12/20/2011] [Indexed: 11/25/2022]
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16
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Abstract
Since the localization and discovery of the first high-risk breast cancer (BC) genes in 1990, there has been a substantial progress in unravelling its familial component. Increasing numbers of women at risk of BC are coming forward requesting advice on their risk and what they can do about it. Three groups of genetic predisposition alleles have so far been identified with high-risk genes conferring 40-85% lifetime risk including BRCA1, BRCA2 and TP53. Moderate risk genes (20-40% risk) including PALB1, BRIP, ATM and CHEK2, and a host of low-risk common alleles identified largely through genome-wide association studies. Currently, only BRCA1, BRCA2 and TP53 are used in clinical practice on a wide scale, although testing of up to 50-100 gene loci may be possible in the future utilizing next-generation technology.
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Affiliation(s)
- F Lalloo
- Genetic Medicine, The University of Manchester, Manchester Academic Health Science Centre, St Mary's Hospital, Central Manchester Hospitals Foundation Trust, Manchester M13 9WL, UK
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17
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Evans DGR, Lalloo F, Ashcroft L, Shenton A, Clancy T, Baildam AD, Brain A, Hopwood P, Howell A. Uptake of risk-reducing surgery in unaffected women at high risk of breast and ovarian cancer is risk, age, and time dependent. Cancer Epidemiol Biomarkers Prev 2009; 18:2318-24. [PMID: 19661091 DOI: 10.1158/1055-9965.epi-09-0171] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The uptake of risk-reducing surgery in women at increased risk of breast and ovarian cancer is highly variable between countries and centers within countries. We have investigated the rate, timing, and age of uptake of surgery in the northwest of England to report the results after up to 7 years in a Regional Genetics center. METHODS Uptake was documented in 211 known unaffected BRCA1/2 mutation carriers from 509 families and in 3,515 women at >25% lifetime risk of breast cancer without known mutations. RESULTS Of the 211 mutation carriers, 40% opted for bilateral risk-reducing mastectomy (BRRM) and 45% underwent bilateral risk-reducing salpingo-oophorectomy (BRRSPO). Uptake of BRRM was significantly related to lifetime risk and age but continued over several years. In women not known to carry a BRCA mutation, 6.4% of women at 40% to 45% lifetime risk, 2.5% of women at 33% to 39% lifetime risk, and 1.8% of women at 25% to 32% lifetime risk underwent BRRM (P < 0.005). BRRSPO uptake was greater in BRCA1 (52%) than BRCA2 (28%) carriers but in both groups tended to occur within the first 2 years after gene test (except in the youngest age group) and in women between the ages of 35 and 45. CONCLUSION To truly assess the uptake of risk-reducing surgery, longer-term follow-up is necessary particularly in younger women who are likely to delay BRRSPO. Careful risk counseling does seem to influence women's decisions for surgery, although the effect is not immediate.
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Affiliation(s)
- D Gareth R Evans
- Regional Genetic Service, The University of Manchester, St.Mary's Hospital, Manchester, United Kingdom.
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18
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Evans DG, Lunt P, Clancy T, Eeles R. Childhood predictive genetic testing for Li-Fraumeni syndrome. Fam Cancer 2009; 9:65-9. [PMID: 19404774 DOI: 10.1007/s10689-009-9245-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Accepted: 04/15/2009] [Indexed: 11/24/2022]
Abstract
Presymptomatic genetic testing in childhood for adult onset conditions is generally discouraged as it does not directly benefit the child and removes their autonomy. In certain cancer prone conditions such as Familial Adenomatous Polyposis and Von Hippel Lindau disease there are risks of disease in childhood and benefit to children not inheriting a mutation in being able to forego unpleasant screening tests. Li-Fraumeni syndrome caused by constitutional TP53 mutations there are also implications in childhood with a risk of around 20% of a childhood malignancy. However, as yet no evidence based surveillance programme has been identified. We describe our experience of childhood testing for four children in two Li-Fraumeni families caused by TP53 mutations.
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Affiliation(s)
- D G Evans
- Medical Genetics Research Group and Regional Genetics Service, University of Manchester and Central Manchester Foundation Hospital NHS Trust, St Mary's Hospital, Manchester, M13 0JH, UK.
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19
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Baildam AD. Best surgical prophylaxis - risk-reducing mastectomy for women at high personal risk of breast cancer. Breast 2006; 15 Suppl 2:S21-5. [PMID: 17382857 DOI: 10.1016/s0960-9776(07)70013-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Andrew D Baildam
- Department of Breast Surgery, Withington Hospital, South Manchester University Hospitals Trust, Manchester UK
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20
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Evans DGR, Lalloo F, Hopwood P, Maurice A, Baildam A, Brain A, Barr L, Howell A. Surgical decisions made by 158 women with hereditary breast cancer aged <50 years. Eur J Surg Oncol 2005; 31:1112-8. [PMID: 16005602 DOI: 10.1016/j.ejso.2005.05.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Revised: 05/12/2005] [Accepted: 05/18/2005] [Indexed: 11/15/2022] Open
Abstract
AIM To establish the uptake of contralateral risk reducing mastectomy in women informed of their risks and options at time of diagnosis of their primary unilateral breast cancer. METHODS We have assessed the surgical choices of 70 women diagnosed with breast cancer <50 years as part of a family history surveillance program and fully informed about their contralateral risks and surgical options. We have compared this to women from other surgical clinics who were subsequently found to harbour a pathogenic BRCA1/2 mutation. RESULTS Sixty-five percent (13/20) of BRCA1/2 mutation carriers and 59% (n=20/34) of those at the highest level of risk pre-diagnosis (33+% lifetime risk) opted for contra-lateral mastectomy in the study sample. In contrast only 10% (n=9/88) women identified as mutation carriers from other clinics opted for such surgery. CONCLUSIONS We would suggest that women with a significant family history and therefore a high contra-lateral breast cancer risk, should have these risks and management options discussed at the time of diagnosis of breast cancer.
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Affiliation(s)
- D G R Evans
- Academic Unit of Medical Genetics and Regional Genetics Service, St Mary's Hospital, Hathersage Road, Manchester, UK.
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21
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Sauven P. Guidelines for the management of women at increased familial risk of breast cancer. Eur J Cancer 2004; 40:653-65. [PMID: 15010065 DOI: 10.1016/j.ejca.2003.10.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2003] [Revised: 10/20/2003] [Accepted: 10/20/2003] [Indexed: 11/25/2022]
Abstract
The Guidelines were prepared by an international expert panel on behalf of the Association of Breast Surgery. The majority of women who have a relative with breast cancer are not themselves at significantly increased risk. The Guidelines propose a management strategy, including genetic assessment, chemo-prevention, risk reducing surgery and radiological screening, based on risk assessment of the individual. The Guidelines are based on evidence where available, or on consensus statements from surgeons, radiologists, geneticists and clinical psychologists.
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Affiliation(s)
- P Sauven
- The Breast Unit, Broomfield Hospital, Chelmsford CM1 7ET, UK.
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22
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Abstract
The demand for genetic services by women with a family history of breast cancer has increased exponentially over the last few years. It is important that risks to women are accurately assessed and that processes are in place for appropriate counselling and management. The classification of risk into average, moderate, and high, depending upon the assessed lifetime risk of breast cancer, allows for the management of moderate risk women within cancer units and high risk women within the regional genetic centres. Management of high risk women includes discussion of options including screening, chemoprevention, and preventive surgery. The majority of these options are still unproven in the long term and continuing research is needed for their evaluation. Mutation screening and predictive testing are now a reality for a minority of families, allowing for a more informed basis for decisions regarding management options.
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Affiliation(s)
- D G R Evans
- University Department of Medical Genetics and Regional Genetics Service, St Mary's Hospital, Manchester M13 0JH, UK.
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Stefanek M, Hartmann L, Nelson W. RESPONSE: Re: Risk-Reduction Mastectomy: Clinical Issues and Research Needs. J Natl Cancer Inst 2002. [DOI: 10.1093/jnci/94.4.307-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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24
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Evans DG, Howell A, Baildam A, Brain A, Lalloo F, Hopwood P. Re: risk-reduction mastectomy: clinical issues and research needs. J Natl Cancer Inst 2002; 94:307-8. [PMID: 11854394 DOI: 10.1093/jnci/94.4.307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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