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Wong SM, Apostolova C, Eisenberg E, Foulkes WD. Counselling Framework for Germline BRCA1/2 and PALB2 Carriers Considering Risk-Reducing Mastectomy. Curr Oncol 2024; 31:350-365. [PMID: 38248108 PMCID: PMC10814079 DOI: 10.3390/curroncol31010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Female BRCA1/2 and PALB2 germline pathogenic variant carriers have an increased lifetime risk of breast cancer and may wish to consider risk-reducing mastectomy (RRM) for surgical prevention. Quantifying the residual lifetime risk and absolute benefit from RRM requires careful consideration of a patient's age, pathogenic variant, and their personal history of breast or ovarian cancer. Historically, patients have been counselled that RRM does not necessarily prolong survival relative to high-risk surveillance, although recent studies suggest a possible survival benefit of RRM in BRCA1 carriers. The uptake of RRM has increased dramatically over the last several decades yet varies according to sociodemographic factors and geographic region. The increased adoption of nipple-sparing mastectomy techniques, ability to avoid axillary staging, and availability of reconstructive options for most germline pathogenic variant carriers has helped to minimize the morbidity of RRM. Preoperative discussions should include evidence regarding postmastectomy sensation, the potential for supplemental surgery, pregnancy-related chest wall changes, and the need for continued clinical surveillance. Approaches that include sensation preservation and robotic nipple-sparing mastectomy are an area of evolving research that may be more widely adopted in the future.
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Affiliation(s)
- Stephanie M. Wong
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
| | - Carla Apostolova
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Elisheva Eisenberg
- Department of Surgery, McGill University, Montreal, QC H3G 1A4, Canada
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - William D. Foulkes
- Stroll Cancer Prevention Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC H4A 3T2, Canada
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada
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Record SM, Thomas SM, Ntowe K, Chiba A, Plichta JK. BRCA1/2 mutation carriers & risk reducing mastectomy: Who undergoes surgery and potential benefits. Am J Surg 2024; 227:146-152. [PMID: 37827871 PMCID: PMC10842097 DOI: 10.1016/j.amjsurg.2023.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/29/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Risk-reducing mastectomy (RRM) is the most effective breast cancer risk-reduction strategy in BRCA1/2 mutation carriers. We examined factors associated with RRM and its relationship with overall survival (OS). METHODS Patients aged 18-80y at diagnosis of their BRCA1/2 mutation were selected from our institutional database and stratified by RRM receipt. Differences were tested; unadjusted OS was estimated. RESULTS Of the 306 patients, median age was 43y; median follow-up was 41.6mo. Patients undergoing RRM were more often married with a history of pregnancy (both p ≤ 0.05). Of female patients, 23.1% underwent RRM. Two patients had malignancy detected at RRM, and one developed breast cancer after RRM. Higher unadjusted OS was observed with RRM (p = 0.02). CONCLUSIONS Our analyses suggest that family-structure may play a role in a patient's decision to undergo RRM. We also demonstrated RRM is likely associated with improved survival, potentially underscoring the importance of this option for BRCA1/2 mutation carriers.
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Affiliation(s)
- Sydney M Record
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University, Durham, NC, USA; Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Koumani Ntowe
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Akiko Chiba
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.
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Liu T, Yu J, Gao Y, Ma X, Jiang S, Gu Y, Ming WK. Prophylactic Interventions for Hereditary Breast and Ovarian Cancer Risks and Mortality in BRCA1/2 Carriers. Cancers (Basel) 2023; 16:103. [PMID: 38201529 PMCID: PMC10778044 DOI: 10.3390/cancers16010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/16/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Hereditary breast and ovarian cancers (HBOCs) pose significant health risks worldwide and are mitigated by prophylactic interventions. However, a meta-analysis of their efficacy and the impact of different genetic variants on their effectiveness is lacking. METHODS A systematic review and meta-analysis were conducted, adhering to Cochrane guidelines. The review encompassed studies that involved prophylactic interventions for healthy women with BRCA variants, focusing on cancer incidence and mortality outcomes. The Newcastle-Ottawa Scale was used for risk of bias assessment. We pooled the extracted outcomes using random effects models and conducted subgroup analyses stratified by intervention, variant, and cancer types. RESULTS A total of 21 studies met the inclusion criteria. The meta-analysis revealed that prophylactic interventions significantly reduced cancer risk and mortality. The subgroup analysis showed a greater protective effect for BRCA2 than BRCA1 variant carriers. Risk-reducing surgeries (RRS) were more effective than chemoprevention, with RRS notably reducing cancer risk by 56% compared to 39% for chemoprevention. Prophylactic oophorectomy significantly reduced HBOC risks, while the effect of prophylactic mastectomy and chemoprevention on mortality was less conclusive. CONCLUSIONS Prophylactic interventions significantly reduce the risk of HBOC and associated mortality. This comprehensive analysis provides insights for future economic evaluations and clinical decision-making in HBOC interventions.
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Affiliation(s)
- Taoran Liu
- Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong 999077, China
| | - Jing Yu
- Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong 999077, China
| | - Yangyang Gao
- Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong 999077, China
| | - Xinyang Ma
- Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong 999077, China
| | - Shan Jiang
- Macquarie University Centre for the Health Economy, Macquarie Business School and Australian Institute of Health Innovation, Macquarie University, Sydney, NSW 2109, Australia
| | - Yuanyuan Gu
- Macquarie University Centre for the Health Economy, Macquarie Business School and Australian Institute of Health Innovation, Macquarie University, Sydney, NSW 2109, Australia
| | - Wai-kit Ming
- Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong 999077, China
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Witjes VM, Ligtenberg MJL, Vos JR, Braspenning JCC, Ausems MGEM, Mourits MJE, de Hullu JA, Adang EMM, Hoogerbrugge N. The most efficient and effective BRCA1/2 testing strategy in epithelial ovarian cancer: Tumor-First or Germline-First? Gynecol Oncol 2023; 174:121-128. [PMID: 37182432 DOI: 10.1016/j.ygyno.2023.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/13/2023] [Accepted: 04/29/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE Genetic testing in epithelial ovarian cancer (OC) is essential to identify a hereditary cause like a germline BRCA1/2 pathogenic variant (PV). An efficient strategy for genetic testing in OC is highly desired. We evaluated costs and effects of two strategies; (i) Tumor-First strategy, using a tumor DNA test as prescreen to germline testing, and (ii) Germline-First strategy, referring all patients to the clinical geneticist for germline testing. METHODS Tumor-First and Germline-First were compared in two scenarios; using real-world uptake of testing and setting implementation to 100%. Decision analytic models were built to analyze genetic testing costs (including counseling) per OC patient and per family as well as BRCA1/2 detection probabilities. With a Markov model, the life years gained among female relatives with a germline BRCA1/2 PV was investigated. RESULTS Focusing on real-world uptake, with the Tumor-First strategy more OC patients and relatives with a germline BRCA1/2 PV are detected (70% versus 49%), at lower genetic testing costs (€1898 versus €2502 per patient, and €2511 versus €2930 per family). Thereby, female relatives with a germline BRCA1/2 PV can live on average 0.54 life years longer with Tumor-First compared to Germline-First. Focusing on 100% uptake, the genetic testing costs per OC patient are substantially lower in the Tumor-First strategy (€2257 versus €4986). CONCLUSIONS The Tumor-First strategy in OC patients is more effective in identifying germline BRCA1/2 PV at lower genetic testing costs per patient and per family. Optimal implementation of Tumor-First can further improve detection of heredity in OC patients.
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Affiliation(s)
- Vera M Witjes
- Department of Human Genetics, Radboud university medical center, Nijmegen, the Netherlands; Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands
| | - Marjolijn J L Ligtenberg
- Department of Human Genetics, Radboud university medical center, Nijmegen, the Netherlands; Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands; Department of Pathology, Radboud university medical center, Nijmegen, the Netherlands
| | - Janet R Vos
- Department of Human Genetics, Radboud university medical center, Nijmegen, the Netherlands; Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands
| | - Jozé C C Braspenning
- Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands; Department of IQ Healthcare, Radboud university medical center, Nijmegen, the Netherlands
| | - Margreet G E M Ausems
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marian J E Mourits
- Department of Gynecology, University Medical Center Groningen, Groningen, the Netherlands
| | - Joanne A de Hullu
- Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands; Department of Obstetrics and Gynecology, Radboud university medical center, Nijmegen, the Netherlands
| | - Eddy M M Adang
- Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands; Department for Health Evidence, Radboud university medical center, Nijmegen, the Netherlands
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud university medical center, Nijmegen, the Netherlands; Research Institute for Medical Innovation, Radboud university medical center, Nijmegen, the Netherlands.
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Stuursma A, van der Vegt B, Jansen L, Berger LPV, Mourits MJE, de Bock GH. The Effect of Risk-Reducing Salpingo-Oophorectomy on Breast Cancer Incidence and Histopathological Features in Women with a BRCA1 or BRCA2 Germline Pathogenic Variant. Cancers (Basel) 2023; 15:cancers15072095. [PMID: 37046756 PMCID: PMC10093102 DOI: 10.3390/cancers15072095] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Risk-reducing salpingo-oophorectomy (RRSO) is advised for female BRCA1/2 germline pathogenic variant (GPV) carriers to reduce tubal/ovarian cancer risk. RRSO may also affect breast cancer (BC) incidence. The aim was to investigate the effect of RRSO on BC incidence and histopathological features in female BRCA1/2 GPV carriers. Methods: Prospectively collected clinical data from BRCA1/2 GPV carriers in our hospital-based data/biobank were linked to the Dutch Nationwide Pathology Databank (PALGA) in January 2022. Multivariable Cox-proportional hazard models were used to calculate hazard ratios (HRs) with 95% confidence intervals (95% CIs), where the pre-RRSO group was considered the reference group and the primary endpoint was the first primary BC. Histopathological features of BCs pre- and post-RRSO were compared using descriptive statistics. Results: In 1312 women, 164 incident primary BCs were observed. RRSO did not decrease BC risk for BRCA1 GPV (HR: 1.48, 95% CI: 0.91–2.39) or BRCA2 GPV (HR: 0.95, 95% CI: 0.43–2.07) carriers. BCs tended to be smaller post-RRSO (median: 12 mm) than pre-RRSO (15 mm, p: 0.08). There were no statistically significant differences in histopathological features. Conclusions: RRSO did not decrease BC risk or affect BC features in BRCA1/2 GPV in this study, although BCs diagnosed post-RRSO tended to be smaller.
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Lang N, Ayme A, Ming C, Combes JD, Chappuis VN, Friedlaender A, Vuilleumier A, Sandoval JL, Viassolo V, Chappuis PO, Labidi-Galy SI. Chemotherapy-related agranulocytosis as a predictive factor for germline BRCA1 pathogenic variants in breast cancer patients: a retrospective cohort study. Swiss Med Wkly 2023; 153:40055. [PMID: 37011610 DOI: 10.57187/smw.2023.40055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Carriers of germline pathogenic variants of the BRCA1 gene (gBRCA1) tend to have a higher incidence of haematological toxicity upon exposure to chemotherapy. We hypothesised that the occurrence of agranulocytosis during the first cycle of (neo-)adjuvant chemotherapy (C1) in breast cancer (BC) patients could predict gBRCA1 pathogenic variants. PATIENTS AND METHODS The study population included non-metastatic BC patients selected for genetic counselling at Hôpitaux Universitaires de Genève (Jan. 1998 to Dec. 2017) with available mid-cycle blood counts performed during C1. The BOADICEA and Manchester scoring system risk-prediction models were applied. The primary outcome was the predicted likelihood of harbouring gBRCA1 pathogenic variants among patients presenting agranulocytosis during C1. RESULTS Three hundred seven BC patients were included: 32 (10.4%) gBRCA1, 27 (8.8%) gBRCA2, and 248 (81.1%) non-heterozygotes. Mean age at diagnosis was 40 years. Compared with non-heterozygotes, gBRCA1 heterozygotes more frequently had grade 3 BC (78.1%; p = 0.014), triple-negative subtype (68.8%; p <0.001), bilateral BC (25%; p = 0.004), and agranulocytosis following the first cycle of (neo-)adjuvant chemotherapy (45.8%; p = 0.002). Agranulocytosis and febrile neutropenia that developed following the first cycle of chemotherapy were independently predictive for gBRCA1 pathogenic variants (odds ratio: 6.1; p = 0.002). The sensitivity, specificity, positive predictive value, and negative predictive value for agranulocytosis predicting gBRCA1 were 45.8% (25.6-67.2%), 82.8% (77.5-87.3%), 22.9% (6.1-37.3%), and 93.4% (88.9-96.4%), respectively. Agranulocytosis substantially improved the positive predictive value of the risk-prediction models used for gBRCA1 evaluation. CONCLUSION Agranulocytosis following the first cycle of (neo-)adjuvant chemotherapy is an independent predictive factor for gBRCA1 detection in non-metastatic BC patients.
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Affiliation(s)
- Noémie Lang
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Aurélie Ayme
- Department of Diagnostics, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Chang Ming
- Department of Clinical Research, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jean-Damien Combes
- Infections and Cancer Epidemiology Group, International Agency for Research on Cancer, Lyon, France
| | - Victor N Chappuis
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Alex Friedlaender
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Aurélie Vuilleumier
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - José L Sandoval
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Valeria Viassolo
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Pierre O Chappuis
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Department of Diagnostics, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - S Intidhar Labidi-Galy
- Department of Oncology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Department of Diagnostics, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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Deutschmann C, Singer CF, Gschwantler-Kaulich D, Pfeiler G, Leser C, Baltzer PAT, Helbich TH, Kraus C, Korbatits R, Marzogi A, Clauser P. Residual fibroglandular breast tissue after mastectomy is associated with an increased risk of a local recurrence or a new primary breast cancer". BMC Cancer 2023; 23:281. [PMID: 36978031 PMCID: PMC10044359 DOI: 10.1186/s12885-023-10764-y] [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: 05/10/2022] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Residual fibroglandular breast tissue (RFGT) following a mastectomy has been claimed to be associated with the occurrence of an in-breast local recurrence (IBLR) or new primary tumor (NP). Yet, scientific evidence proving this assumption is lacking. The primary aim of the study was to verify whether RFGT following a mastectomy is a risk factor for an IBLR or NP. METHODS This retrospective analysis included all patients that underwent a mastectomy and were followed up at the Department of Obstetrics and Gynecology of the Medical University of Vienna between 01.01.2015 and 26.02.2020. RFGT volume (assessed on magnetic resonance imaging) was correlated with the prevalence of an IBLR and a NP. RESULTS A total of 105 patients (126 breasts) following a therapeutic mastectomy were included. After a mean follow-up of 46.0 months an IBLR had occurred in 17 breasts and a NP in 1 breast. A significant difference in RFGT volume was observed between the disease-free cohort and the subgroup with an IBLR or NP (p = .017). A RFGT volume of ≥ 1153 mm3 increased the risk by the factor 3.57 [95%CI 1.27; 10.03]. CONCLUSIONS RFGT volume is associated with an increased risk for an IBLR or NP.
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Affiliation(s)
- Christine Deutschmann
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Christian F Singer
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daphne Gschwantler-Kaulich
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Pfeiler
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Carmen Leser
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Pascal A T Baltzer
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas H Helbich
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christine Kraus
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ricarda Korbatits
- Department of Obstetrics and Gynecology, Division of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alaa Marzogi
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Paola Clauser
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Isselhard A, Lautz Z, Rhiem K, Stock S. Assessing Psychological Morbidity in Cancer-Unaffected BRCA1/2 Pathogenic Variant Carriers: A Systematic Review. Curr Oncol 2023; 30:3590-3608. [PMID: 37185387 PMCID: PMC10136916 DOI: 10.3390/curroncol30040274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Female BRCA1/2 pathogenic variant carriers have an increased lifetime risk for breast and ovarian cancer. Cancer-unaffected women who are newly diagnosed with this pathogenic variant may experience psychological distress because of imminent health threat. No comprehensible review on psychological morbidity in cancer-unaffected BRCA1/2 pathogenic variant carriers is currently available. This review aims to give an overview about all available the studies in which psychological outcomes have been assessed in cancer-unaffected BRCA1/2 pathogenic variant carriers, whether as a primary outcome or secondary measurement. A systematic search across four databases (Web of Science, PubMed, ScienceDirect, and EBSCO) was conducted. Studies had to report on cancer-unaffected pathogenic variant carriers (exclusively or separately) and use a validated measure of psychological morbidity to be eligible. Measures were only included if they were used in at least three studies. The final review consisted of 45 studies from 13 countries. Distress measures, including anxiety and cancer worry, were most often assessed. Most studies found a peak of distress immediately after genetic test result disclosure, with a subsequent decline over the following months. Only some studies found elevated distress in carriers compared to non-carriers in longer follow-ups. Depression was frequently investigated but largely not found to be of clinical significance. Quality of life seemed to be largely unaffected by a positive genetic test result, although there was some evidence that younger women, especially, were less satisfied with their role functioning in life. Body image has been infrequently assessed so far, but the evidence suggested that there may be a decrease in body image after genetic test result disclosure that may decrease further for women who opt for a prophylactic mastectomy. Across all the outcomes, various versions of instruments were used, often limiting the comparability among the studies. Hence, future research should consider using frequently used instruments, as outlined by this review. Finally, while many studies included cancer-unaffected carriers, they were often not reported on separately, which made it difficult to draw specific conclusions about this population.
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Clarijs ME, van Egdom LSE, Verhoef C, Vasilic D, Koppert LB. Bilateral prophylactic mastectomy: should we preserve the pectoral fascia? Protocol of a Dutch double blinded, prospective, randomised controlled pilot study with a within-subject design (PROFAS). BMJ Open 2023; 13:e066728. [PMID: 36806067 PMCID: PMC9944307 DOI: 10.1136/bmjopen-2022-066728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
INTRODUCTION Bilateral prophylactic mastectomy (BPM) in women with a high risk of developing breast cancer has shown to provide the greatest risk reduction. Many surgical guidelines recommend the removal of the pectoral fascia (PF) in mastectomies; however, there is no evidence to support this statement. Reported wound-related complications following mastectomy include seroma, flap necrosis, infection and haematoma. Seroma causes discomfort and may delay the reconstructive procedures. Whether removal or preservation of the PF influences drain volume, seroma formation and other postoperative complications following BPM remains unclear. The aim of this study is to assess the impact of removal versus preservation of the PF on drain policy and seroma after BPM. METHODS AND ANALYSIS This is a double blinded, prospective, randomised controlled pilot study with a within-subject design. The inclusion criteria are women >18 years, presenting in the Academic Breast Cancer Centre Rotterdam, who are opting for BPM. Patients with a history or diagnosis of breast cancer are excluded. According to the sample size calculation based on the difference in total drain volume, a number of 21 eligible patients will be included. Randomisation will occur within the patient, which means PF preservation in one breast and PF removal in the contralateral breast. The primary study endpoint is total drainage volume. Secondary study outcomes include time to drain removal, number of needle aspirations, postoperative complications and length of hospital stay. ETHICS AND DISSEMINATION The study is approved by the Erasmus Medical Center Review Board (REC 2020-0431). Results will be presented during international conferences and published in a peer-reviewed academic journal. TRIAL REGISTRATION NUMBER NCT05391763; clinicaltrials.gov.
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Affiliation(s)
- Marloes E Clarijs
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, The Netherlands
| | - Laurentine S E van Egdom
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, The Netherlands
| | - Dalibor Vasilic
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, Zuid-Holland, The Netherlands
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10
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Isselhard A, Lautz Z, Töpper M, Rhiem K, Schmutzler R, Vitinius F, Fischer H, Berger-Höger B, Steckelberg A, Beifus K, Köberlein-Neu J, Stock S. Coping Self-Efficacy and Its Relationship with Psychological Morbidity after Genetic Test Result Disclosure: Results from Cancer-Unaffected BRCA1/2 Mutation Carriers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1684. [PMID: 36767056 PMCID: PMC9914784 DOI: 10.3390/ijerph20031684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 06/18/2023]
Abstract
Women who are found to carry a BRCA1/2 pathogenic variant experience psychological distress due to an increased risk of breast and ovarian cancer. They may decide between different preventive options. In this secondary analysis of data collected alongside a larger randomized controlled trial, we are looking at 130 newly found BRCA1/2 pathogenic variant carriers and how their coping self-efficacy immediately after genetic test result disclosure is related to their psychological burden and status of preventive decision making. Participants received the Coping Self-Efficacy Scale, the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the Decisional Conflict Scale, and the Stage of Decision-Making Scale after positive genetic test result disclosure. We found that women with higher coping self-efficacy showed fewer symptoms of anxiety or depression and were less affected by receiving the genetic test result in terms of post-traumatic stress. However, coping self-efficacy had no relationship with any decision-related criteria, such as decisional conflict or stage of decision making. This shows that despite its buffering capacity on psychological burden, possessing coping self-efficacy does not lead to more decisiveness in preference-sensitive decisions.
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Affiliation(s)
- Anna Isselhard
- Institute of Health Economics and Clinical Epidemiology, University Hospital Cologne, 50924 Cologne, Germany
| | - Zoe Lautz
- Institute of Health Economics and Clinical Epidemiology, University Hospital Cologne, 50924 Cologne, Germany
| | - Maren Töpper
- Institute of Health Economics and Clinical Epidemiology, University Hospital Cologne, 50924 Cologne, Germany
| | - Kerstin Rhiem
- Center for Hereditary Breast and Ovarian Cancer and Center for Integrated Oncology (CIO), Medical Faculty, University Hospital Cologne, 50924 Cologne, Germany
| | - Rita Schmutzler
- Center for Hereditary Breast and Ovarian Cancer and Center for Integrated Oncology (CIO), Medical Faculty, University Hospital Cologne, 50924 Cologne, Germany
| | - Frank Vitinius
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine, University Hospital Cologne, 50924 Cologne, Germany
| | - Hannah Fischer
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine, University Hospital Cologne, 50924 Cologne, Germany
| | - Birte Berger-Höger
- Institute for Public Health and Nursing Research, University of Bremen, 28359 Bremen, Germany
- Institute for Health and Nursing Science, Faculty of Medicine Martin Luther University Halle-Wittenberg, 06112 Halle (Saale), Germany
| | - Anke Steckelberg
- Institute for Health and Nursing Science, Faculty of Medicine Martin Luther University Halle-Wittenberg, 06112 Halle (Saale), Germany
| | - Karolina Beifus
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, 42119 Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, 42119 Wuppertal, Germany
| | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, University Hospital Cologne, 50924 Cologne, Germany
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11
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Ohsumi S, Nakamura S, Miyata H, Watanabe C, Den H, Arai M. Risk-reducing mastectomy for women with hereditary breast and ovarian cancer (HBOC): analytical results of data from the Japanese Organization of HBOC. Jpn J Clin Oncol 2022; 52:1265-1269. [PMID: 35905458 DOI: 10.1093/jjco/hyac120] [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: 04/13/2021] [Accepted: 07/09/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Risk-reducing mastectomy is one option for women with hereditary breast and ovarian cancer to reduce the risk of breast cancer. PATIENTS AND METHODS We analyzed data of the Japanese Organization of Hereditary Breast and Ovarian Cancer on women who were diagnosed as hereditary breast and ovarian cancer by BRCA germline genetic testing between 2010 and 2019 to reveal the rate and likelihood of risk-reducing mastectomy. RESULTS There were 412 women with BRCA1, 271 with BRCA2 and 4 with both female pathogenic variants. Ninety (13.1%) received risk-reducing mastectomy. The rates of risk-reducing mastectomy were statistically significantly higher in women with BRCA1 pathogenic variants than BRCA2, in women who had breast cancer than those who did not, in women with a breast cancer family history than in those without, in mothers than in those without children, in women who were receiving surveillance with MRI than those who were not and in women who received risk-reducing salpingo-oophorectomy than in those who did not on univariate analyses. The ages when they received the genetic testing were statistically significantly younger in the women receiving risk-reducing mastectomy than those who did not receive it. The women with BRCA1 pathogenic variants, personal history of breast cancer, mothers, those receiving MRI surveillance and younger women were independently significantly more likely to receive risk-reducing mastectomy based on multivariate analysis. CONCLUSIONS The rate of risk-reducing mastectomy was not high in Japan; however, risk-reducing surgery was approved by the Japanese National Medical Insurance for hereditary breast and ovarian cancer patients with breast and/or ovarian cancer in 2020, so this rate will increase.
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Affiliation(s)
- Shozo Ohsumi
- Department of Breast Oncology, NHO Shikoku Cancer Center, Matsuyama, Japan
| | - Seigo Nakamura
- Division of Breast Surgical Oncology, Department of Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Chie Watanabe
- School of Nursing and Rehabilitation Sciences, Showa University, Tokyo, Japan
| | - Hiroki Den
- Department of Hygiene, Public Health, and Preventative Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Masami Arai
- Department of Clinical Genetics, Juntendo University, Graduate School of Medicine, Tokyo, Japan
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12
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Functions of Breast Cancer Predisposition Genes: Implications for Clinical Management. Int J Mol Sci 2022; 23:ijms23137481. [PMID: 35806485 PMCID: PMC9267387 DOI: 10.3390/ijms23137481] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023] Open
Abstract
Approximately 5–10% of all breast cancer (BC) cases are caused by germline pathogenic variants (GPVs) in various cancer predisposition genes (CPGs). The most common contributors to hereditary BC are BRCA1 and BRCA2, which are associated with hereditary breast and ovarian cancer (HBOC). ATM, BARD1, CHEK2, PALB2, RAD51C, and RAD51D have also been recognized as CPGs with a high to moderate risk of BC. Primary and secondary cancer prevention strategies have been established for HBOC patients; however, optimal preventive strategies for most hereditary BCs have not yet been established. Most BC-associated CPGs participate in DNA damage repair pathways and cell cycle checkpoint mechanisms, and function jointly in such cascades; therefore, a fundamental understanding of the disease drivers in such cascades can facilitate the accurate estimation of the genetic risk of developing BC and the selection of appropriate preventive and therapeutic strategies to manage hereditary BCs. Herein, we review the functions of key BC-associated CPGs and strategies for the clinical management in individuals harboring the GPVs of such genes.
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13
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Carneiro VCG, Gifoni ACLVC, Mauro Rossi B, Andrade CEMDC, Lima FTD, Galvão HDCR, Casali da Rocha JC, Silva Barreto LSD, Ashton‐Prolla P, Guindalini RSC, Farias TPD, Andrade WP, Fernandes PHDS, Ribeiro R, Lopes A, Tsunoda AT, Azevedo BRB, Marins CAM, Oliveira Uchôa DNDA, Dos Santos EAS, Fernández Coimbra FJ, Dias Filho FA, Lopes FCDO, Fernandes FG, Ritt GF, Laporte GA, Guimaraes GC, Feitosa e Castro Neto H, dos Santos JC, de Carvalho Vilela JB, Meinhardt Junior JG, Cunha JRD, Medeiros Milhomem L, da Silva LM, Maciel LDF, Ramalho NM, Leite Nunes R, Guido de Araújo R, de Assunção Ehrhardt R, Delgado Bocanegra RE, Silva Junior TC, Oliveira VRD, Silva Surimã W, de Melo Melquiades M, Ribeiro HSDC, Oliveira AF. Cancer risk‐reducing surgery: Brazilian society of surgical oncology guideline part 1 (gynecology and breast). J Surg Oncol 2022; 126:10-19. [DOI: 10.1002/jso.26812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Vandré Cabral Gomes Carneiro
- Department of Surgey, Gynecology, Oncology Instituto de Medicina Integral Professor Fernando Figueira Recife Brazil
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
- Department of Oncogenetic, Oncology Oncologia D'or Rio de Janeiro Brazil
| | | | - Benedito Mauro Rossi
- Department of Oncogenetic, Surgical Oncology Hospital Sírio Libanês São Paulo Brazil
| | | | - Fernanda Teresa de Lima
- Department of Oncogenetic Hospital Israelita Albert Einstein São Paulo Brazil
- Department of Oncogenetic UNIFESP‐EPM São Paulo Brazil
| | | | | | | | | | | | | | - Wesley Pereira Andrade
- Department of Surgery Hospital Beneficência Portuguesa São Paulo Brazil
- Department of Surgery Hospital Oswaldo Cruz São Paulo Brazil
- Department of Surgery Hospital Santa Catarina São Paulo Brazil
| | | | - Reitan Ribeiro
- Department of Surgical Oncology Hospital Erasto Gaertner Curitiba Brazil
| | - Andre Lopes
- Department of Surgical Oncology São Camilo Oncologia São Paulo Brazil
| | - Audrey Tieko Tsunoda
- Department of Surgical Oncology Hospital Erasto Gaertner Curitiba Brazil
- Department of Surgery Pontifícia Universidade Católica do Paraná Curitiba Brazil
| | - Bruno Roberto Braga Azevedo
- Department of Surgical Oncology Oncoclínicas Curitiba Brazil
- Department of Surgery Pilar Hospital Curitiba Brazil
| | - Carlos Augusto Martinez Marins
- Department of Head and Neck, Oncological Surgery INCA Rio de Janeiro Brazil
- Department of Surgery Hospital Federal dos Servidores do Estado Rio de Janeiro Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jorge Guardiola Meinhardt Junior
- Department of Surgery Santa Casa de Misericórdia de Porto Alegre Porto Alegre Brazil
- Department of Surgery Hospital Santa Rita Porto Alegre Brazil
| | | | | | - Luciana Mata da Silva
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
| | | | - Nathalia Moreira Ramalho
- Department of Surgey, Gynecology, Oncology Instituto de Medicina Integral Professor Fernando Figueira Recife Brazil
- Department of Oncogenetic, Oncology Oncologia D'or Rio de Janeiro Brazil
| | - Rafael Leite Nunes
- Department of Surgery GNDI Notredame Intermédica—Hospital Salvalus São Paulo Brazil
| | - Rodrigo Guido de Araújo
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
| | | | | | | | | | | | | | - Heber Salvador de Castro Ribeiro
- Department of Oncogenetic, Abdominal Surgery A. C. Camargo Cancer Center São Paulo Brazil
- SBCO 2021‐2023 BBSO presidente Rio de Janeiro Brazil
| | - Alexandre Ferreira Oliveira
- Department of Surgery Universidade Federal de Juiz de Fora Juiz de Fora Brazil
- SBCO 2019‐2021 BBSO presidente Rio de Janeiro Brazil
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14
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Bilateral Prophylactic Nipple-Sparing Mastectomy: Analysis of the Risk-Reducing Effect in BRCA1/2 Mutation Carriers. Aesthetic Plast Surg 2022; 46:706-711. [PMID: 34342702 DOI: 10.1007/s00266-021-02506-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mutations in the BRCA1 or BRCA2 genes increase the lifetime risk of developing breast cancer to 68-72% by the age of 80. One of the modalities to manage the risk is a prophylactic mastectomy. Bilateral nipple-sparing mastectomy specifically offers the most favorable esthetic outcomes but the evidence for its oncological safety remains limited. Thus, we aimed to compare the occurrence of breast cancer between nipple-sparing mastectomy and surveillance groups of BRCA1 or BRCA 2 mutations carriers. MATERIALS AND METHODS BRCA1 or BRCA2-positive patients undergoing bilateral prophylactic nipple-sparing mastectomy at our department were identified. Only those unaffected by breast cancer were eligible. Each patient was pair-matched with a BRCA1 or BRCA2-positive patient of equal age from the surveillance group. Breast cancer incidence in both groups was recorded and the results were compared. RESULTS None of 105 patients who underwent NSM between 2009 and 2019 at a single institution with a mean follow-up time of 50 months developed breast cancer over this time period. One patient in this group died of an unrelated cause. Nine patients from 105 in the match-paired surveillance group were diagnosed with breast cancer during a mean follow-up time of 58.3 months, however, none of them died. CONCLUSION To the best of our knowledge, this is the largest single-center study of risk-reducing bilateral NSM in healthy BRCA1 or BRCA2 mutation carriers. Based on our results and those of other series, we conclude that NSM in its current form appears to be at least equally as safe as other types of mastectomy for preventing breast cancer in BRCA1 or BRCA2 mutation carriers. 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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15
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Wang X, Chang MD, Lee MC, Niell BL. The Breast Cancer Screening and Timing of Breast MRI—Experience in a Genetic High-Risk Screening Clinic in a Comprehensive Cancer Center. Curr Oncol 2022; 29:2119-2131. [PMID: 35323371 PMCID: PMC8947675 DOI: 10.3390/curroncol29030171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022] Open
Abstract
For women with genetic risk of breast cancer, the addition of screening breast MRI to mammography has become a standard. The order and interval of annual imaging can be variable among providers. To evaluate the clinical implications related to the timing, we conducted a chart review on a cohort of women (N = 276) with high-risk (BRCA1, BRCA2, CDH1, PTEN and TP53) and moderate high-risk (ATM and CHEK2) predisposition to breast cancer in a 48-month follow up. The estimated MRI detection rate in the entire group is 1.75% (18 per 1000 MRI tests). For the high-risk group, the estimated rate is 2.98% (30 per 1000 MRI tests). Many women discovered their genetic risk at an age much older (average age of the high-risk group was 48 years) than the age recommended to initiate enhanced screening (age 20 to 25 years). In total, 4 of the 11 primary breast cancers detected were identified by screening MRI within the first month after initial visit, which were not detected by previous mammography, suggesting the benefit of initiating MRI immediately after the discovery of genetic risk. Breast screening findings for women with Lynch syndrome and neurofibromatosis type 1 were also included in this report.
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Affiliation(s)
- Xia Wang
- GeneHome, Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
- Correspondence:
| | - Maxine D. Chang
- GeneHome, Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Marie Catherine Lee
- Department of Breast Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Bethany L. Niell
- Division of Breast Imaging, Department of Diagnostic Imaging, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
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16
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Fu X, Tan W, Song Q, Pei H, Li J. BRCA1 and Breast Cancer: Molecular Mechanisms and Therapeutic Strategies. Front Cell Dev Biol 2022; 10:813457. [PMID: 35300412 PMCID: PMC8921524 DOI: 10.3389/fcell.2022.813457] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022] Open
Abstract
Breast cancer susceptibility gene 1 (BRCA1) is a tumor suppressor gene, which is mainly involved in the repair of DNA damage, cell cycle regulation, maintenance of genome stability, and other important physiological processes. Mutations or defects in the BRCA1 gene significantly increase the risk of breast, ovarian, prostate, and other cancers in carriers. In this review, we summarized the molecular functions and regulation of BRCA1 and discussed recent insights into the detection and treatment of BRCA1 mutated breast cancer.
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Affiliation(s)
- Xiaoyu Fu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China.,Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wei Tan
- Department of Biochemistry and Molecular Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Qibin Song
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - Huadong Pei
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Juanjuan Li
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China.,Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China
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17
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Christofyllakis K, Bittenbring JT, Thurner L, Ahlgrimm M, Stilgenbauer S, Bewarder M, Kaddu-Mulindwa D. Cost-effectiveness of precision cancer medicine-current challenges in the use of next generation sequencing for comprehensive tumour genomic profiling and the role of clinical utility frameworks (Review). Mol Clin Oncol 2021; 16:21. [PMID: 34909199 DOI: 10.3892/mco.2021.2453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/30/2021] [Indexed: 12/21/2022] Open
Abstract
Precision cancer medicine (PCM) is an emerging paradigm in oncology, which includes tumour comprehensive genomic profiling (CGP) to enable molecularly guided therapy. However, cost-effectiveness analyses of PCM are faced with several challenges and, thus, its cost-effectiveness remains unclear. Early trials using only molecularly guided therapy were faced with the challenge of providing adequate measures of outcome, which probably explains the modest treatment benefits demonstrated. Endpoints like the progression-free survival (PFS)2/PFS1 ratio may assist in overcoming this issue. Moreover, specific tumour subtypes appear to benefit more from PCM. Costs associated with next-generation sequencing (NGS) for CGP are decreasing, but targeted therapy itself represents a major cost driver. CGP not only enables prediction of response to treatment, but also resistance, and could thus prevent administration of unnecessary (and costly) therapies. In clinical practice, the presence of clinical frameworks, such as the Recommendations for the Use of NGS for Patients with Metastatic Cancers from the ESMO Precision Medicine Working Group, and the ESMO Scale for Clinical Actionability of Molecular Targets, are essential in appropriately identifying situations where PCM is clinically meaningful, thereby improving its cost-effectiveness.
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Affiliation(s)
- Konstantinos Christofyllakis
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany
| | - Joerg Thomas Bittenbring
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany
| | - Lorenz Thurner
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany
| | - Manfred Ahlgrimm
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany
| | - Stephan Stilgenbauer
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany.,Ulm Comprehensive Cancer Center, Ulm University Hospital, D-89081 Ulm, Germany.,Department of Internal Medicine III, Ulm University Hospital, D-89081 Ulm, Germany
| | - Moritz Bewarder
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany
| | - Dominic Kaddu-Mulindwa
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, Saarland University Medical Center, D-66421 Homburg, Germany
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18
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Conduit C, Milne RL, Friedlander ML, Phillips KA. Bilateral Salpingo-oophorectomy and Breast Cancer Risk for BRCA1 and BRCA2 Mutation Carriers: Assessing the Evidence. Cancer Prev Res (Phila) 2021; 14:983-994. [PMID: 34348913 PMCID: PMC9662899 DOI: 10.1158/1940-6207.capr-21-0141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 07/20/2021] [Indexed: 01/07/2023]
Abstract
Without preventive interventions, women with germline pathogenic variants in BRCA1 or BRCA2 have high lifetime risks for breast cancer and tubo-ovarian cancer. The increased risk for breast cancer starts at a considerably younger age than that for tubo-ovarian cancer. Risk-reducing bilateral salpingo-oophorectomy (rrBSO) is effective in reducing tubo-ovarian cancer risk for BRCA1 and BRCA2 mutation carriers, but whether it reduces breast cancer risk is less clear. All studies of rrBSO and breast cancer risk are observational in nature and subject to various forms of bias and confounding, thus limiting conclusions that can be drawn about causation. Early studies supported a statistically significant protective association for rrBSO on breast cancer risk, which is reflected by several international guidelines that recommend consideration of premenopausal rrBSO for breast cancer risk reduction. However, these historical studies were hampered by the presence of several important biases, including immortal person-time bias, confounding by indication, informative censoring, and confounding by other risk factors, which may have led to overestimation of any protective benefit. Contemporary studies, specifically designed to reduce some of these biases, have yielded contradictory results. Taken together, there is no clear and consistent evidence for a role of premenopausal rrBSO in reducing breast cancer risk in BRCA1 or BRCA2 mutation carriers.
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Affiliation(s)
- Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Michael L. Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Barker St. Randwick, New South Wales, Australia
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia.,Corresponding Author: Kelly-Anne Phillips, Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St., Melbourne, Victoria, 3000, Australia. Phone: 613-8559-7902; Fax: 613-8559-7739; E-mail:
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19
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Riis M. Management of patients with BRCA mutation from the point of view of a breast surgeon. Ann Med Surg (Lond) 2021; 65:102311. [PMID: 33996049 PMCID: PMC8091883 DOI: 10.1016/j.amsu.2021.102311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/24/2022] Open
Abstract
Germ-line mutation in BRCA (BReast CAncer gene) 1 or BRCA2 are found in 3–4% of all women with breast cancer. These patients have a significant increased risk of breast and ovarian cancer. They are often younger when diagnosed with the mutation, and the possible breast cancer they get is often aggressive with inferior outcome. There are risk reducing strategies, and the most powerful strategy is risk reducing surgery, both risk reducing bilateral mastectomy (RRM) and risk reducing bilateral salpino-oophorectomy (PBSO). This review is meant to address breast surgery in patients with germline BRCA mutation. The guidelines and techniques applied is under continuous change and it is important for the clinicians to be well informed to provide the patient with the information needed for them to make an informed decision on what risk strategy to choose. Patients with germ-line mutation in BRCA1 or BRCA2 have a significant increased risk of breast and ovarian cancer. There are different risk reducing strategies and the most powerful strategy is risk-reducing surgery, both risk reducing bilateral mastectomy and risk reducing bilateral salpingo-oophorectomy. Guidelines and techniques for the risk reducing surgery of the breast are under continuous change and improvement. Breast conserving therapy is not associated with worse survival and is a good option for a BRCA mutation carrier diagnosed with breast cancer. Risk-reducing mastectomy can be performed in a later setting. The management of BRCA mutation carriers, both affected and unaffected, should be performed in a multidisciplinary team. Physicians need to be systematically educated and updated on the most recent literature.
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20
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Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting? ACTA ACUST UNITED AC 2021; 28:702-715. [PMID: 33504079 PMCID: PMC7924380 DOI: 10.3390/curroncol28010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 11/17/2022]
Abstract
Breast cancer susceptibility gene (BRCA) mutation carriers have an increased risk of breast cancer. Mitigation of this risk can be achieved via surveillance or prophylactic mastectomy with or without breast reconstruction. Those that choose surgery expect to reduce their chance of developing cancer. The purpose of this study was to determine the incidence of patients developing breast cancer prior to surgery and to identify modifiable contributing factors within the patient journey. This is a historical cohort study of all BRCA mutation carriers identified through the British Columbia Cancer Hereditary Cancer Program between 2000 and 2012. Patients were divided into two groups: surveillance (S) and prophylactic mastectomy with immediate breast reconstruction (PM/IBR). The incidence of cancer, time to PM/IBR and patient journeys were analyzed. A total of 333 women were identified. The time to surgery from mutation disclosure was a median of 31 (5.3, 75.7) months. During this period, 6% of patients developed breast cancer compared with a 14% incidence of breast cancer in patients choosing surveillance. The majority of time to surgery was attributed to the period between mutation disclosure and the decision to proceed with surgery. Strategies to facilitate decision-making as well as wait list prioritization and dedicated operative time should be targeted to this population to decrease the number of women developing an interval cancer prior to surgery.
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21
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Wei G, Kumar A, Lee MC, Wang X. Influential Factors on Risk-reduction Mastectomy in a High-risk Breast Cancer Population With Genetic Predispositions. Clin Breast Cancer 2021; 21:e427-e433. [PMID: 33712364 DOI: 10.1016/j.clbc.2021.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Carriers of deleterious mutations in breast cancer predisposition genes are presented with critical choices regarding cancer risk management. Risk-reduction mastectomy is a major preventative strategy in this population. Understanding the decision-making process for prophylactic mastectomy is essential in patient-centered care for high-risk carriers and patients with breast cancer. We sought to provide insight into influential factors underlying preventative surgery decisions among individuals with high breast cancer risk. MATERIALS AND METHODS We conducted a retrospective chart review of pathogenic carriers of high-risk breast cancer genes who presented to the Moffitt GeneHome clinic between March 2017 and June 2020. Associations between preventative mastectomy choice and influence variables were analyzed via unadjusted and adjusted logistic regression models. RESULTS Of 258 high-risk mutation carriers, 104 (40.3%) underwent risk-reduction mastectomy. A significantly higher proportion of mastectomy patients reported prior history of breast cancer (68.9% vs. 16.5%; P < .001) and history of other risk-reduction or noncancer-related surgeries (61.7% vs. 25.8%; P < .001). Significant predictors affecting surgery decision included previous breast cancer history (adjusted odds ratio [aOR], 10.48; 95% confidence interval [CI], 5.59-19.63; P < .0001), other risk-reduction or noncancer-related surgical history (aOR, 4.65; 95% CI, 2.28-9.47; P < .0001), and age at presentation to the genetics clinic (< 35 years old: aOR, 2.77; 95% CI, 1.04-7.4; P = .042; 35-55 years old: aOR, 2.48; 95% CI, 1.19-5.18; P = .016). CONCLUSIONS Preventive mastectomy decisions are highly personal and complex. In our sample, we observed prior history or concurrent breast cancer, history of other risk-reduction surgery or noncancer-related surgery, and younger age at presentation to the GeneHome clinic to be predictive of mastectomy uptake.
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Affiliation(s)
- Grace Wei
- MD Program, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Ambuj Kumar
- Center for Evidence-based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL
| | - Marie Catherine Lee
- Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Xia Wang
- GeneHome Hereditary Cancer Screening Clinic, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Getachew-Smith H, Ross AA, Scherr CL, Dean M, Clements ML. Previving: How Unaffected Women with a BRCA1/2 Mutation Navigate Previvor Identity. HEALTH COMMUNICATION 2020; 35:1256-1265. [PMID: 31163995 DOI: 10.1080/10410236.2019.1625002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Receiving a positive result for a BRCA1/2 (BRCA) mutation - indicating a high lifetime risk to develop hereditary breast and ovarian cancer - can significantly alter a woman's identity. BRCA-positive women who have not been diagnosed with cancer may be labeled "previvors," which distinguishes those at-risk for developing cancer, but have not had cancer. Using semi-structured interviews (N = 25), this study explored how unaffected BRCA-positive women navigate the previvor identity. Women in this sample differed on their definitions of previvor, views of acceptance, rejection, or ambivalence toward the label, and identification as a previvor. Understanding how women interpret and embrace the previvor identity may help inform communication for those with BRCA genetic mutations, but whom have not been diagnosed with cancer.
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Affiliation(s)
| | - Amy A Ross
- Department of Communication Studies, Northwestern University
| | | | - Marleah Dean
- Department of Communication, University of South Florida
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23
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Wan Q, Hu L, Ouyang T, Li J, Wang T, Fan Z, Fan T, Lin B, Xu Y, Xie Y. Clinical phenotypes combined with saturation genome editing identifying the pathogenicity of BRCA1 variants of uncertain significance in breast cancer. Fam Cancer 2020; 20:85-95. [PMID: 32803532 DOI: 10.1007/s10689-020-00202-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 08/07/2020] [Indexed: 10/23/2022]
Abstract
Characterizing the pathogenicity of BRCA1 variants of uncertain significance (VUSs) is a major bottleneck in clinical management of BRCA1-associated breast cancer. Saturation genome editing (SGE) was recently reported as an innovative laboratory-based approach to assess the pathogenicity of BRCA1 variants. We combined clinical phenotypes and SGE score to identify the pathogenicity of BRCA1 VUSs detected in a cohort of 8,085 breast cancer patients. According to SGE function score, 33 out of 144 BRCA1 VUSs detected were classified into "loss of function" (n = 13), "intermediate" (n = 2), and "functional" (n = 18) groups. Compared with non-carriers, "loss of function" VUS carriers (n = 19) presented significantly worse clinicopathological characteristics. These included younger age at breast cancer diagnosis (44.4 years vs. 51.2 years, P = 0.01), stronger family history of any cancer (57.9% vs. 32.3%, P = 0.017) especially breast or ovarian cancer (47.4% vs. 9.3%, P < 0.001), more bilateral breast cancer (31.6% vs. 3.4%, P < 0.001), and triple-negative breast cancer (47.4% vs. 12.8%, P < 0.001), which were comparable to those of pathogenic variant carriers. In contrast, the clinical phenotypes of "functional" VUS carriers were similar to those of non-carriers. These results indicated that SGE was a reliable method in BRCA1 variant classification. Combining SGE function score and the available evidence, twelve out of 33 BRCA1 VUSs were reclassified as pathogenic or likely pathogenic variants and one was benign.
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Affiliation(s)
- Qiting Wan
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Li Hu
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Tao Ouyang
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Jinfeng Li
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Tianfeng Wang
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Zhaoqing Fan
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Tie Fan
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Benyao Lin
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China
| | - Ye Xu
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China.
| | - Yuntao Xie
- Breast Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, People's Republic of China.
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Alonso Roca S, Delgado Laguna A, Arantzeta Lexarreta J, Cajal Campo B, Santamaría Jareño S. Screening in patients with increased risk of breast cancer (part 1): Pros and cons of MRI screening. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Dullens B, de Putter R, Lambertini M, Toss A, Han S, Van Nieuwenhuysen E, Van Gorp T, Vanderstichele A, Van Ongeval C, Keupers M, Prevos R, Celis V, Dekervel J, Everaerts W, Wildiers H, Nevelsteen I, Neven P, Timmerman D, Smeets A, Denayer E, Van Buggenhout G, Legius E, Punie K. Cancer Surveillance in Healthy Carriers of Germline Pathogenic Variants in BRCA1/2: A Review of Secondary Prevention Guidelines. JOURNAL OF ONCOLOGY 2020; 2020:9873954. [PMID: 32655641 PMCID: PMC7322604 DOI: 10.1155/2020/9873954] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/30/2020] [Indexed: 02/06/2023]
Abstract
Germline pathogenic alterations in the breast cancer susceptibility genes 1 (BRCA1) and 2 (BRCA2) are the most prevalent causes of hereditary breast and ovarian cancer. The increasing trend in proportion of cancer patients undergoing genetic testing, followed by predictive testing in families of new index patients, results in a significant increase of healthy germline BRCA1/2 mutation carriers who are at increased risk for breast, ovarian, and other BRCA-related cancers. This review aims to give an overview of available screening guidelines for female and male carriers of pathogenic or likely pathogenic germline BRCA1/2 variants per cancer type, incorporating malignancies that are more or less recently well correlated with BRCA1/2. We selected guidelines from national/international organizations and/or professional associations that were published or updated between January 1, 2015, and February 1, 2020. In total, 12 guidelines were included. This review reveals several significant discordances between the different guidelines. Optimal surveillance strategies depend on accurate age-specific cancer risk estimates, which are not reliably available for all BRCA-related cancers. Up-to-date national or international consensus guidelines are of utmost importance to harmonize counseling and proposed surveillance strategies for BRCA1/2 carriers.
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Affiliation(s)
- Boudewijn Dullens
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
| | - Robin de Putter
- Department of Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Matteo Lambertini
- Department of Medical Oncology, U.O.C Clinica di Oncologia Médica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Angela Toss
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Sileny Han
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Els Van Nieuwenhuysen
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Toon Van Gorp
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Adriaan Vanderstichele
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Chantal Van Ongeval
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Machteld Keupers
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Renate Prevos
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Valerie Celis
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Dekervel
- Digestive Oncology, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Everaerts
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Hans Wildiers
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
| | - Ines Nevelsteen
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Neven
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Timmerman
- Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Ann Smeets
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen Denayer
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Griet Van Buggenhout
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Eric Legius
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
- Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Kevin Punie
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
- Multidisciplinary Breast Centre, UZ-KU Leuven Cancer Institute (LKI), University Hospitals Leuven, Leuven, Belgium
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26
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Valero MG, Moo TA, Muhsen S, Zabor EC, Stempel M, Pusic A, Gemignani ML, Morrow M, Sacchini V. Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer. Br J Surg 2020; 107:1307-1312. [PMID: 32432359 DOI: 10.1002/bjs.11616] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/02/2019] [Accepted: 03/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis. METHODS Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated. RESULTS A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses. CONCLUSION These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.
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Affiliation(s)
- M G Valero
- Breast Service, Department of Surgery, New York, USA
| | - T-A Moo
- Breast Service, Department of Surgery, New York, USA
| | - S Muhsen
- Breast Service, Department of Surgery, New York, USA
| | - E C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Stempel
- Breast Service, Department of Surgery, New York, USA
| | - A Pusic
- Division of Plastic Surgery, Brigham and Women's Hospital at Harvard Medical School, Boston, Massachusetts, USA
| | - M L Gemignani
- Breast Service, Department of Surgery, New York, USA
| | - M Morrow
- Breast Service, Department of Surgery, New York, USA
| | - V Sacchini
- Breast Service, Department of Surgery, New York, USA
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27
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Dickinson BP, Holmes D, Vu‐Huynh N, Vu MB, Snyder L, MacDonald H, Guerra L, Coleman C, Fancher C, Hamoui N, Khan S, Kim S, Lopez J, Overstreet J, Ashjian PH. Autologous mastectomy reconstruction: Communication among the breast surgery team to maximize aesthetic and oncologic outcome. Breast J 2020; 26:1771-1780. [DOI: 10.1111/tbj.13874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Brian P. Dickinson
- Brian P. Dickinson, M.D., Inc. Newport Beach California USA
- Glendale Adventist Medical Center Glendale California USA
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | - Dennis Holmes
- Glendale Adventist Medical Center Glendale California USA
| | | | - Monica B. Vu
- Brian P. Dickinson, M.D., Inc. Newport Beach California USA
| | - Lincoln Snyder
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | | | - Lisa Guerra
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
- Breastlink Orange California
| | - Colleen Coleman
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | - Crystal Fancher
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | - Nahid Hamoui
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | - Sadia Khan
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | - Sadie Kim
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | - January Lopez
- Hoag Memorial Hospital Presbyterian Newport Beach California USA
| | | | - Peter H. Ashjian
- Brian P. Dickinson, M.D., Inc. Newport Beach California USA
- Glendale Adventist Medical Center Glendale California USA
- Peter Ashjian, M.D., Inc. Glendale California USA
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28
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Alonso Roca S, Delgado Laguna AB, Arantzeta Lexarreta J, Cajal Campo B, Santamaría Jareño S. Screening in patients with increased risk of breast cancer (part 1): pros and cons of MRI screening. RADIOLOGIA 2020; 62:252-265. [PMID: 32241593 DOI: 10.1016/j.rx.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 12/23/2019] [Accepted: 01/30/2020] [Indexed: 12/31/2022]
Abstract
Screening plays an important role in women with a high risk of breast cancer. Given this population's high incidence of breast cancer and younger age of onset compared to the general population, it is recommended that screening starts earlier. There is ample evidence that magnetic resonance imaging (MRI) is the most sensitive diagnostic tool, and American and the European guidelines both recommend annual MRI screening (with supplementary annual mammography) as the optimum screening modality. Nevertheless, the current guidelines do not totally agree about the recommendations for MRI screening in some subgroups of patients. The first part of this article on screening in women with increased risk of breast cancer reviews the literature to explain and evaluate the advantages of MRI screening compared to screening with mammography alone: increased detection of smaller cancers with less associated lymph node involvement and a reduction in the rate of interval cancers, which can have an impact on survival and mortality (with comparable effects to other preventative measures). At the same time, however, we would like to reflect on the drawbacks of MRI screening that affect its applicability.
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Affiliation(s)
- S Alonso Roca
- Servicio de Radiodiagnóstico, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | - A B Delgado Laguna
- Servicio de Radiodiagnóstico, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - J Arantzeta Lexarreta
- Servicio de Radiodiagnóstico, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - B Cajal Campo
- Servicio de Radiodiagnóstico, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - S Santamaría Jareño
- Servicio de Radiodiagnóstico, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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29
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Kurian AW, Ward KC, Abrahamse P, Hamilton AS, Deapen D, Morrow M, Jagsi R, Katz SJ. Association of Germline Genetic Testing Results With Locoregional and Systemic Therapy in Patients With Breast Cancer. JAMA Oncol 2020; 6:e196400. [PMID: 32027353 PMCID: PMC7042883 DOI: 10.1001/jamaoncol.2019.6400] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/07/2019] [Indexed: 12/14/2022]
Abstract
Importance The increasing use of germline genetic testing may have unintended consequences on treatment. Little is known about how women with pathogenic variants in cancer susceptibility genes are treated for breast cancer. Objective To determine the association of germline genetic testing results with locoregional and systemic therapy use in women diagnosed with breast cancer. Design, Setting, and Participants For this population-based cohort study, data from women aged 20 years or older who were diagnosed with stages 0 to III breast cancer between 2014 and 2016 were accrued from the Surveillance, Epidemiology and End Results (SEER) registries of Georgia and California. The women underwent genetic testing within 3 months after diagnosis and were reported to the Georgia and California SEER registries by December 1, 2017. Exposures Pathogenic variant status based on linked results of clinical germline genetic testing by 4 laboratories that did most such testing in the studied regions. Main Outcomes and Measures Potential deviation of treatment from practice guidelines was assessed in the following clinical scenarios: (1) surgery: receipt of bilateral mastectomy by women eligible for less extensive unilateral surgery (unilateral breast tumor); (2) radiotherapy: omission in women indicated for postlumpectomy radiotherapy (all lumpectomy recipients except age ≥70 with stage I, estrogen and/or progesterone receptor [ER/PR] positive, ERBB2 [formerly HER2]-negative disease); and (3) chemotherapy: receipt by women eligible to consider chemotherapy omission (stages I-II, ER/PR-positive, ERBB2-negative, and 21-gene recurrence score of 0-30, which was the upper limit of the intermediate risk range during the study years). The adjusted percentage treated and adjusted odds ratio (OR) are reported based on multivariable modeling for each treatment-eligible group. Results A total of 20 568 women (17.3%) of 119 198 were eligible (mean [SD] age, 51.4 [12.2]). Compared with women whose test results were negative, those with BRCA1/2 pathogenic variants were more likely to receive bilateral mastectomy for a unilateral tumor (61.7% vs 24.3%; OR, 5.52, 95% CI, 4.73-6.44), less likely to receive postlumpectomy radiotherapy (50.2% vs 81.5%; OR, 0.22, 95% CI, 0.15-0.32), and more likely to receive chemotherapy for early-stage, ER/PR-positive disease (38.0% vs 30.3%; OR, 1.76, 95% CI, 1.31-2.34). Similar patterns were seen with pathogenic variants in other breast cancer-associated genes (ATM, CDH1, CHEK2, NBN, NF1, PALB2, PTEN, and TP53) but not with variants of uncertain significance. Conclusions and Relevance Women with pathogenic variants in BRCA1/2 and other breast cancer-associated genes were found to have distinct patterns of breast cancer treatment; these may be less concordant with practice guidelines, particularly for radiotherapy and chemotherapy.
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Affiliation(s)
- Allison W. Kurian
- Department of Medicine, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paul Abrahamse
- Department of Medicine, University of Michigan School of Public Health, Ann Arbor
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor
| | - Ann S. Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Dennis Deapen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Steven J. Katz
- Department of Medicine, University of Michigan School of Public Health, Ann Arbor
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor
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30
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Improving Cost-efficiency in Bilateral Direct-to-Implant Reconstructions with Acellular Dermal Matrix. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2447. [PMID: 31942404 PMCID: PMC6908385 DOI: 10.1097/gox.0000000000002447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/15/2019] [Indexed: 11/27/2022]
Abstract
The use of acellular dermal matrix (ADM) for bilateral breast reconstruction has increased in recent years. Detection of BCRA mutation and therefore bilateral risk-reduction mastectomy is one of the main reasons for this increase. High cost of ADM is considered a major drawback for its use. The authors present a new technique which allows the use of only one unit of ADM for both breasts. After assessing the viability of the skin of mastectomy flaps, a musculofascial pocket formed superiorly by pectoralis major, laterally by serratus fascia and inferiorly by rectus fascia, is performed. Then, the ADM is divided in two halves. We propose two different ways to divide the matrix, cutting it vertically or diagonally in two. The way in which the matrix should be cut depends on the distensibility of the pocket. Afterwards, the implant is inserted and the exposed area of the implant is covered by the ADM sutured to the edges of the musculofascial pocket. Using only one ADM unit for bilateral reconstruction, the procedure becomes not only more cost-effective but also can reduce complications such as seroma, rippling, wrinkling, and visibility by means of a better coverage with lesser foreign body load. Furthermore, the lesser the matrix used, the faster the integration is achieved.
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31
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van Egdom LSE, de Kock MA, Apon I, Mureau MAM, Verhoef C, Hazelzet JA, Koppert LB. Patient-Reported Outcome Measures may optimize shared decision-making for cancer risk management in BRCA mutation carriers. Breast Cancer 2019; 27:426-434. [PMID: 31832891 PMCID: PMC7196093 DOI: 10.1007/s12282-019-01033-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022]
Abstract
Purpose The aim of this study was to compare patient-reported outcomes (PROs) of BRCA1/2 mutation carriers, either after bilateral prophylactic mastectomy (BPM) or during breast surveillance, to improve shared decision-making in their cancer risk management. Methods Unaffected BRCA1/2 mutation carriers at least one year after BPM followed by immediate breast reconstruction (BPM-IBR) or one year under surveillance were eligible. After informed consent, the Hospital Anxiety and Depression Scale (HADS) and BREAST-Q were administered and compared between the different strategies. PROs were also compared to available normative data. Results Ninety-six participants were analyzed in this study and showed significant differences between strategies in age, age at genetic testing, and time since BPM or starting breast surveillance. All HADS scores were below 8 suggesting no signs of anxiety or depression in both groups. Higher mean ‘Q-physical well-being’ scores were reported by the surveillance group (81.78 [CI 76.99–86.57]) than the BPM group (76.96 [CI 73.16 – 80.75]; p = 0.011). Overall, for both questionnaires better scores were seen when compared to age-matched normative data. Conclusions No signs of anxiety or depression were seen in the surveillance or BPM-IBR group. Slightly better mean BREAST-Q scores were seen for the surveillance group in comparison to BPM-IBR, except for ‘Q-psychological well-being’. The difference in ‘Q-physical well-being’ was significantly worse for BPM-IBR. Approaches to obtain longitudinal PROs and reference values should be explored in the future, which could add value to shared decision-making in regards to breast cancer risk management in this specific patient population.
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Affiliation(s)
- L S E van Egdom
- Department of Surgical Oncology, RG-228, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, P.O. 2040, 3000 CA, Rotterdam, The Netherlands
| | - M A de Kock
- Department of Surgical Oncology, RG-228, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, P.O. 2040, 3000 CA, Rotterdam, The Netherlands
| | - I Apon
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, RG-228, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, P.O. 2040, 3000 CA, Rotterdam, The Netherlands
| | - J A Hazelzet
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - L B Koppert
- Department of Surgical Oncology, RG-228, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, P.O. 2040, 3000 CA, Rotterdam, The Netherlands.
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Risk-reducing mastectomy in BRCA carriers: survival is not the issue. Breast Cancer Res Treat 2019; 179:251-252. [PMID: 31541380 DOI: 10.1007/s10549-019-05440-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
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Jakub JW, Peled AW, Gray RJ, Greenup RA, Kiluk JV, Sacchini V, McLaughlin SA, Tchou JC, Vierkant RA, Degnim AC, Willey S. Oncologic Safety of Prophylactic Nipple-Sparing Mastectomy in a Population With BRCA Mutations: A Multi-institutional Study. JAMA Surg 2019; 153:123-129. [PMID: 28903167 DOI: 10.1001/jamasurg.2017.3422] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance; however, its role among patients with BRCA mutations remains controversial. Objective To report on the oncologic safety of NSM and provide evidence-based data to patients and health care professionals regarding preservation of the nipple-areolar complex during a risk-reducing mastectomy in a population with BRCA mutations. Design, Setting, and Participants We retrospectively reviewed the outcomes of 9 institutions' experience with prophylactic NSM from 1968 to 2013 in a cohort of patients with BRCA mutations. Patients with breast cancer were included if they underwent contralateral risk-reducing mastectomy; however, only the prophylactic side was considered in the analysis. Patients found to have an occult primary breast cancer at the time of risk-reducing mastectomy, those having variant(s) of unknown significance, and those undergoing free nipple grafts were excluded. Main Outcomes and Measures The primary outcome measure was development of a new breast cancer after risk-reducing NSM. Three reference data sources were used to model the expected number of events, and this was compared with our observed number of events. Results A total of 548 risk-reducing NSMs in 346 patients were performed at 9 institutions. The median age at NSM was 41 years (interquartile range, 34.5-47.5 years). Bilateral prophylactic NSMs were performed in 202 patients (58.4%), and 144 patients (41.6%) underwent a unilateral risk-reducing NSM secondary to cancer in the contralateral breast. Overall, 201 patients with BRCA1 mutations and 145 with BRCA2 mutations were included. With median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Breast cancer did not develop in any patients undergoing bilateral risk-reducing NSMs. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Prophylactic NSM resulted in a significant reduction in breast cancer events (test of observed vs expected events, P < .001). Conclusions and Relevance Nipple-sparing mastectomies are highly preventive against breast cancer in a BRCA population. Although the follow-up remains relatively short, NSM should be offered as a breast cancer risk-reducing strategy to appropriate patients with BRCA mutations.
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Affiliation(s)
- James W Jakub
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anne Warren Peled
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco
| | | | - Rachel A Greenup
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John V Kiluk
- Department of Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Virgilio Sacchini
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Julia C Tchou
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania Medical Center, Philadelphia
| | - Robert A Vierkant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shawna Willey
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC
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Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2019; 322:652-665. [PMID: 31429903 DOI: 10.1001/jama.2019.10987] [Citation(s) in RCA: 261] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Potentially harmful mutations of the breast cancer susceptibility 1 and 2 genes (BRCA1/2) are associated with increased risk for breast, ovarian, fallopian tube, and peritoneal cancer. For women in the United States, breast cancer is the most common cancer after nonmelanoma skin cancer and the second leading cause of cancer death. In the general population, BRCA1/2 mutations occur in an estimated 1 in 300 to 500 women and account for 5% to 10% of breast cancer cases and 15% of ovarian cancer cases. OBJECTIVE To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer. EVIDENCE REVIEW The USPSTF reviewed the evidence on risk assessment, genetic counseling, and genetic testing for potentially harmful BRCA1/2 mutations in asymptomatic women who have never been diagnosed with BRCA-related cancer, as well as those with a previous diagnosis of breast, ovarian, tubal, or peritoneal cancer who have completed treatment and are considered cancer free. In addition, the USPSTF reviewed interventions to reduce the risk for breast, ovarian, tubal, or peritoneal cancer in women with potentially harmful BRCA1/2 mutations, including intensive cancer screening, medications, and risk-reducing surgery. FINDINGS For women whose family or personal history is associated with an increased risk for harmful mutations in the BRCA1/2 genes, or who have an ancestry associated with BRCA1/2 gene mutations, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are moderate. For women whose personal or family history or ancestry is not associated with an increased risk for harmful mutations in the BRCA1/2 genes, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are small to none. Regardless of family or personal history, the USPSTF found adequate evidence that the overall harms of risk assessment, genetic counseling, genetic testing, and interventions are small to moderate. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. (B recommendation) The USPSTF recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 gene mutations. (D recommendation).
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Affiliation(s)
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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Nelson HD, Pappas M, Cantor A, Haney E, Holmes R. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:666-685. [PMID: 31429902 DOI: 10.1001/jama.2019.8430] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Pathogenic mutations in breast cancer susceptibility genes BRCA1 and BRCA2 increase risks for breast, ovarian, fallopian tube, and peritoneal cancer in women; interventions reduce risk in mutation carriers. OBJECTIVE To update the 2013 US Preventive Services Task Force review on benefits and harms of risk assessment, genetic counseling, and genetic testing for BRCA1/2-related cancer in women. DATA SOURCES Cochrane libraries; MEDLINE, PsycINFO, EMBASE (January 1, 2013, to March 6, 2019, for updates; January 1, 1994, to March 6, 2019, for new key questions and populations); reference lists. STUDY SELECTION Discriminatory accuracy studies, randomized clinical trials (RCTs), and observational studies of women without recently diagnosed BRCA1/2-related cancer. DATA EXTRACTION AND SYNTHESIS Data on study methods, setting, population characteristics, eligibility criteria, interventions, numbers enrolled and lost to follow-up, outcome ascertainment, and results were abstracted. Two reviewers independently assessed study quality. MAIN OUTCOMES AND MEASURES Cancer incidence and mortality; discriminatory accuracy of risk assessment tools for BRCA1/2 mutations; benefits and harms of risk assessment, genetic counseling, genetic testing, and risk-reducing interventions. RESULTS For this review, 103 studies (110 articles; N = 92 712) were included. No studies evaluated the effectiveness of risk assessment, genetic counseling, and genetic testing in reducing incidence and mortality of BRCA1/2-related cancer. Fourteen studies (n = 43 813) of 8 risk assessment tools to guide referrals to genetic counseling demonstrated moderate to high accuracy (area under the receiver operating characteristic curve, 0.68-0.96). Twenty-eight studies (n = 8060) indicated that genetic counseling was associated with reduced breast cancer worry, anxiety, and depression; increased understanding of risk; and decreased intention for testing. Twenty studies (n = 4322) showed that breast cancer worry and anxiety were higher after testing for women with positive results and lower for others; understanding of risk was higher after testing. In 8 RCTs (n = 54 651), tamoxifen (relative risk [RR], 0.69 [95% CI, 0.59-0.84]; 4 trials), raloxifene (RR, 0.44 [95% CI, 0.24-0.80]; 2 trials), and aromatase inhibitors (RR, 0.45 [95% CI, 0.26-0.70]; 2 trials) were associated with lower risks of invasive breast cancer compared with placebo; results were not specific to mutation carriers. Mastectomy was associated with 90% to 100% reduction in breast cancer incidence (6 studies; n = 2546) and 81% to 100% reduction in breast cancer mortality (1 study; n = 639); oophorectomy was associated with 69% to 100% reduction in ovarian cancer (2 studies; n = 2108); complications were common with mastectomy. CONCLUSIONS AND RELEVANCE Among women without recently diagnosed BRCA1/2-related cancer, the benefits and harms of risk assessment, genetic counseling, and genetic testing to reduce cancer incidence and mortality have not been directly evaluated by current research.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Elizabeth Haney
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Rebecca Holmes
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
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Ochaney P, Patel K, Haq F, Reese R, Igel S. The Importance of Risk-Reducing Prophylactic Mastectomy in Breast Cancer (BRCA) Carriers: A Case Report. Cureus 2019; 11:e5311. [PMID: 31592366 PMCID: PMC6773448 DOI: 10.7759/cureus.5311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Genetic changes along with environmental exposures can play a role in the development of cancer. Individuals with significant risk factors for breast cancer including family history should be encouraged to undergo genetic testing along with breast cancer screening at an early age. Individuals who test positive for the breast cancer (BRCA) 1 or 2 gene can discuss potential risk-reducing management options, such as risk-reducing prophylactic mastectomy, with their physicians in order to protect them from the long-term consequences of developing breast cancer.
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Affiliation(s)
| | - Komal Patel
- Osteopathic Medicine, Nova Southeastern University, Davie, USA
| | - Furqan Haq
- Internal Medicine, Oak Hill Hospital, Tampa, USA
| | - Robyn Reese
- Obstetrics and Gynecology, Mease Countryside, Largo, USA
| | - Stephen Igel
- Obstetrics and Gynecology, Largo Medical Center, Largo, USA
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Heemskerk-Gerritsen BAM, Jager A, Koppert LB, Obdeijn AIM, Collée M, Meijers-Heijboer HEJ, Jenner DJ, Oldenburg HSA, van Engelen K, de Vries J, van Asperen CJ, Devilee P, Blok MJ, Kets CM, Ausems MGEM, Seynaeve C, Rookus MA, Hooning MJ. Survival after bilateral risk-reducing mastectomy in healthy BRCA1 and BRCA2 mutation carriers. Breast Cancer Res Treat 2019; 177:723-733. [PMID: 31302855 PMCID: PMC6745043 DOI: 10.1007/s10549-019-05345-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/02/2019] [Indexed: 12/14/2022]
Abstract
Background In healthy BRCA1/2 mutation carriers, bilateral risk-reducing mastectomy (BRRM) strongly reduces the risk of developing breast cancer (BC); however, no clear survival benefit of BRRM over BC surveillance has been reported yet. Methods In this Dutch multicenter cohort study, we used multivariable Cox models with BRRM as a time-dependent covariable to estimate the associations between BRRM and the overall and BC-specific mortality rates, separately for BRCA1 and BRCA2 mutation carriers. Results During a mean follow-up of 10.3 years, 722 out of 1712 BRCA1 (42%) and 406 out of 1145 BRCA2 (35%) mutation carriers underwent BRRM. For BRCA1 mutation carriers, we observed 52 deaths (20 from BC) in the surveillance group, and 10 deaths (one from BC) after BRRM. The hazard ratios were 0.40 (95% CI 0.20–0.90) for overall mortality and 0.06 (95% CI 0.01–0.46) for BC-specific mortality. BC-specific survival at age 65 was 93% for surveillance and 99.7% for BRRM. For BRCA2 mutation carriers, we observed 29 deaths (7 from BC) in the surveillance group, and 4 deaths (no BC) after BRRM. The hazard ratio for overall mortality was 0.45 (95% CI 0.15–1.36). BC-specific survival at age 65 was 98% for surveillance and 100% for BRRM. Conclusion BRRM was associated with lower mortality than surveillance for BRCA1 mutation carriers, but for BRCA2 mutation carriers, BRRM may lead to similar BC-specific survival as surveillance. Our findings support a more individualized counseling based on BRCA mutation type. Electronic supplementary material The online version of this article (10.1007/s10549-019-05345-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A Inge-Marie Obdeijn
- Department of Radiology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Margriet Collée
- Department of Clinical Genetics, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Denise J Jenner
- Department of Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Klaartje van Engelen
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Jakob de Vries
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Christi J van Asperen
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter Devilee
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Marinus J Blok
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - C Marleen Kets
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Margreet G E M Ausems
- Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Caroline Seynaeve
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - Matti A Rookus
- Department of Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Maartje J Hooning
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
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High-risk breast cancer surveillance with MRI: 10-year experience from the German consortium for hereditary breast and ovarian cancer. Breast Cancer Res Treat 2019; 175:217-228. [DOI: 10.1007/s10549-019-05152-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 01/21/2023]
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Affiliation(s)
- Susan M Domchek
- Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia
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Kotsopoulos J. BRCA Mutations and Breast Cancer Prevention. Cancers (Basel) 2018; 10:E524. [PMID: 30572612 PMCID: PMC6315560 DOI: 10.3390/cancers10120524] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/05/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Women who inherit a deleterious BRCA1 or BRCA2 mutation face substantially increased risks of developing breast cancer, which is estimated at 70%. Although annual screening with magnetic resonance imaging (MRI) and mammography promotes the earlier detection of the disease, the gold standard for the primary prevention of breast cancer remains bilateral mastectomy. In the current paper, I review the evidence regarding the management of healthy BRCA mutation carriers, including key risk factors and protective factors, and also discuss potential chemoprevention options. I also provide an overview of the key findings from the literature published to date, with a focus on data from studies that are well-powered, and preferably prospective in nature.
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Affiliation(s)
- Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, 6th Floor, Toronto, ON M5S 1B2, Canada.
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7, Canada.
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Pollom EL, Qian Y, Chin AL, Dirbas FM, Asch SM, Kurian AW, Horst KC, Tsai CJ. Rising rates of bilateral mastectomy with reconstruction following neoadjuvant chemotherapy. Int J Cancer 2018; 143:3262-3272. [PMID: 29992582 PMCID: PMC6263854 DOI: 10.1002/ijc.31747] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 01/04/2023]
Abstract
Neoadjuvant chemotherapy (NAC) is used to allow more limited breast surgery without compromising local control. We sought to evaluate nationwide surgical trends in patients with operable breast cancer treated with NAC and factors associated with surgical type. We used the National Cancer Database to identify 235,339 women with unilateral T1-3 N0-3 M0 breast cancer diagnosed between 2010 and 2014 and treated with surgery and chemotherapy. Of these, 59,568 patients (25.3%) were treated with NAC. Rates of pathological complete response (pCR) to NAC increased from 33.3% at the start of the study period in 2010 to 46.3% at the end of the period in 2014 (p = 0.02). Rates of breast-conserving surgery (BSC) changed little, from 37.0 to 40.8% (p = 0.22). Although rates of unilateral mastectomy decreased from 43.3 to 34.7% (p = 0.02) and rates of bilateral mastectomy without immediate reconstruction remained similar (11.7-11.5%; p = 0.82), rates of bilateral mastectomy with immediate reconstruction rose from 8.0 to 13.1% (p = 0.02). Patients who were younger, with private/managed care insurance, and diagnosed in more recent years were more likely to achieve pCR; however, these same characteristics were associated with receipt of bilateral mastectomy (vs. BCS). In addition, non-Hispanic white ethnic and higher area education attainment were both associated with bilateral mastectomy. These findings did not differ by age or molecular subtype. Further study of nonclinical factors that influence selection of more extensive surgery despite excellent response to NAC is warranted.
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Affiliation(s)
- Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Yushen Qian
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | | | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University, Stanford, CA
| | - Allison W Kurian
- Department of Medicine (Oncology) and Health Research and Policy, Stanford University, Stanford, CA
| | - Kathleen C Horst
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Trends in use of bilateral prophylactic mastectomy vs high-risk surveillance in unaffected carriers of inherited breast cancer syndromes in the Inherited Cancer Registry (ICARE). Breast Cancer Res Treat 2018; 174:39-45. [PMID: 30474778 DOI: 10.1007/s10549-018-5057-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Awareness of inherited breast cancer has increased bilateral prophylactic mastectomy (BPM) among unaffected genetic mutation carriers, yet many still choose surveillance. We aimed to identify differences among women electing BPM vs high-risk surveillance. METHODS Participants from an IRB-approved database recruited from 11/2000 to 01/2017 with a deleterious/pathogenic, variant suspected deleterious, or likely pathogenic mutation in ≥ 1 of 11 genes with increased risk for breast cancer (per 2017 NCCN guidelines) were identified. Participants with breast cancer and males were excluded. Sociodemographic and clinical data were collected. The BPM and high-risk surveillance groups were compared using Wilcoxon, Fisher's Exact, and Pearson's Chi-Square analyses. RESULTS A total of 304 unaffected genetic mutation carriers were identified; 22 men were excluded. 113/282 (40%) underwent BPM. There was no significant difference in age, race, marital status, high school graduates, family history of breast cancer, breast biopsies, chemoprevention use, or understanding implications of genetic mutation carriage. BPM participants were more likely to have a prior pregnancy (p = 0.0005), college education (p = 0.04), income > $50,000/year (p = 0.01), first-degree relative with breast cancer (p = 0.04), higher total number of relatives with breast cancer (p = 0.01), and rate of risk-reducing salpingo-oophorectomy (p = < 0.0001). The high-risk surveillance group was more likely to have a history of ovarian cancer (p = 0.009) and cancer worry (p = < 0.0001). CONCLUSIONS BPM is a common but not universal choice among unaffected genetic carriers of inherited breast cancer syndromes. Parity, education, income, ovarian cancer history, first-degree relatives with breast cancer, and cancer worry play significant roles in these decisions.
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Wöckel A, Festl J, Stüber T, Brust K, Stangl S, Heuschmann PU, Albert US, Budach W, Follmann M, Janni W, Kopp I, Kreienberg R, Kühn T, Langer T, Nothacker M, Scharl A, Schreer I, Link H, Engel J, Fehm T, Weis J, Welt A, Steckelberg A, Feyer P, König K, Hahne A, Kreipe HH, Knoefel WT, Denkinger M, Brucker S, Lüftner D, Kubisch C, Gerlach C, Lebeau A, Siedentopf F, Petersen C, Bartsch HH, Schulz-Wendtland R, Hahn M, Hanf V, Müller-Schimpfle M, Henscher U, Roncarati R, Katalinic A, Heitmann C, Honegger C, Paradies K, Bjelic-Radisic V, Degenhardt F, Wenz F, Rick O, Hölzel D, Zaiss M, Kemper G, Budach V, Denkert C, Gerber B, Tesch H, Hirsmüller S, Sinn HP, Dunst J, Münstedt K, Bick U, Fallenberg E, Tholen R, Hung R, Baumann F, Beckmann MW, Blohmer J, Fasching PA, Lux MP, Harbeck N, Hadji P, Hauner H, Heywang-Köbrunner S, Huober J, Hübner J, Jackisch C, Loibl S, Lück HJ, von Minckwitz G, Möbus V, Müller V, Nöthlings U, Schmidt M, Schmutzler R, Schneeweiss A, Schütz F, Stickeler E, Thomssen C, Untch M, Wesselmann S, Bücker A, Krockenberger M. Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 1 with Recommendations for the Screening, Diagnosis and Therapy of Breast Cancer. Geburtshilfe Frauenheilkd 2018; 78:927-948. [PMID: 30369626 PMCID: PMC6202580 DOI: 10.1055/a-0646-4522] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 01/04/2023] Open
Abstract
Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Methods The process of updating the S3 guideline dating from 2012 was based on the adaptation of identified source guidelines which were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and the results of a systematic search of literature databases and the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point to develop recommendations and statements which were modified and graded in a structured consensus procedure. Recommendations Part 1 of this short version of the guideline presents recommendations for the screening, diagnosis and follow-up care of breast cancer. The importance of mammography for screening is confirmed in this updated version of the guideline and forms the basis for all screening. In addition to the conventional methods used to diagnose breast cancer, computed tomography (CT) is recommended for staging in women with a higher risk of recurrence. The follow-up concept includes suggested intervals between physical, ultrasound and mammography examinations, additional high-tech diagnostic procedures, and the determination of tumor markers for the evaluation of metastatic disease.
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Affiliation(s)
- Achim Wöckel
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Jasmin Festl
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Tanja Stüber
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Katharina Brust
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Stephanie Stangl
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | - Peter U. Heuschmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | | | - Wilfried Budach
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Ina Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | | | - Thorsten Kühn
- Frauenklinik, Klinikum Esslingen, Esslingen, Germany
| | - Thomas Langer
- Office des Leitlinienprogrammes Onkologie, Berlin, Germany
| | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | - Anton Scharl
- Frauenklinik, Klinikum St. Marien Amberg, Amberg, Germany
| | | | - Hartmut Link
- Praxis für Hämatologie und Onkologie, Kaiserslautern, Germany
| | - Jutta Engel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Tanja Fehm
- Universitätsfrauenklinik Düsseldorf, Düsseldorf, Germany
| | - Joachim Weis
- Stiftungsprofessur Selbsthilfeforschung, Tumorzentrum/CCC Freiburg, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Anja Welt
- Innere Klinik (Tumorforschung), Westdeutsches Tumorzentrum, Universitätsklinikum Essen, Essen, Germany
| | | | - Petra Feyer
- Klinik für Strahlentherapie und Radioonkologie, Vivantes Klinikum, Neukölln Berlin, Germany
| | - Klaus König
- Berufsverband der Frauenärzte, Steinbach, Germany
| | | | - Hans H. Kreipe
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Wolfram Trudo Knoefel
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Denkinger
- AGAPLESION Bethesda Klinik, Geriatrie der Universität Ulm, Ulm, Germany
| | - Sara Brucker
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin, Universitätsklinikum Charité, Berlin, Germany
| | - Christian Kubisch
- Institut für Humangenetik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Gerlach
- III. Medizinische Klinik und Poliklinik, uct, Interdisziplinäre Abteilung für Palliativmedizin, Universitätsmedizin der Johannes Gutenberg Universität, Mainz, Germany
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Cordula Petersen
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Markus Hahn
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Volker Hanf
- Frauenklinik Nathanstift, Klinikum Fürth, Fürth, Germany
| | | | | | - Renza Roncarati
- Frauenselbsthilfe nach Krebs – Bundesverband e. V., Bonn, Germany
| | - Alexander Katalinic
- Institut für Sozialmedizin und Epidemiologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Christoph Heitmann
- Ästhetisch plastische und rekonstruktive Chirurgie, Camparihaus München, München, Germany
| | | | - Kerstin Paradies
- Konferenz Onkologischer Kranken- und Kinderkrankenpflege, Hamburg, Germany
| | - Vesna Bjelic-Radisic
- Universitätsfrauenklinik, Abteilung für Gynäkologie, Medizinische Universität Graz, Graz, Austria
| | - Friedrich Degenhardt
- Klinik für Frauenheilkunde und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany
| | - Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Oliver Rick
- Klinik Reinhardshöhe Bad Wildungen, Bad Wildungen, Germany
| | - Dieter Hölzel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Matthias Zaiss
- Praxis für interdisziplinäre Onkologie & Hämatologie, Freiburg, Germany
| | | | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Denkert
- Institut für Pathologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Rostock, Germany
| | - Hans Tesch
- Centrum für Hämatologie und Onkologie Bethanien, Frankfurt, Germany
| | | | - Hans-Peter Sinn
- Pathologisches Institut, Universität Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Karsten Münstedt
- Frauenklinik Offenburg, Ortenau Klinikum Offenburg-Gengenbach, Offenburg, Germany
| | - Ulrich Bick
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Fallenberg
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Reina Tholen
- Deutscher Verband für Physiotherapie, Referat Bildung und Wissenschaft, Köln, Germany
| | - Roswita Hung
- Frauenselbsthilfe nach Krebs, Wolfsburg, Germany
| | - Freerk Baumann
- Centrum für Integrierte Onkologie Köln, Uniklinik Köln, Köln, Germany
| | - Matthias W. Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jens Blohmer
- Klinik für Gynäkologie incl. Brustzentrum, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter A. Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael P. Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nadia Harbeck
- Brustzentrum, Frauenklinik, Universität München (LMU), München, Germany
| | - Peyman Hadji
- Klinik für Gynäkologie und Geburtshilfe, Krankenhaus Nordwest, Frankfurt, Germany
| | - Hans Hauner
- Lehrstuhl für Ernährungsmedizin, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | | | | | - Jutta Hübner
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | | | | | | | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Nöthlings
- Institut für Ernährungs- und Lebensmittelwissenschaften, Rheinische Friedrich-Wilhelms Universität Bonn, Bonn, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Rita Schmutzler
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Andreas Schneeweiss
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Florian Schütz
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Michael Untch
- Klinik für Geburtshilfe und Gynäkologie, Helios Klinikum Berlin-Buch, Berlin, Germany
| | | | - Arno Bücker
- Klinik für Diagnostische und Interventionelle Radiologie am UKS, Universität des Saarlandes, Homburg, Germany
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Dossa F, Cusimano MC, Sutradhar R, Metcalfe K, Little T, Lerner-Ellis J, Eisen A, Meschino WS, Baxter NN. Real-world health services utilisation and outcomes after BRCA1 and BRCA2 testing in Ontario, Canada: the What Comes Next Cohort Study protocol. BMJ Open 2018; 8:e025317. [PMID: 30181190 PMCID: PMC6129086 DOI: 10.1136/bmjopen-2018-025317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Women who have pathogenic mutations in the BRCA1 and BRCA2 genes are at greatly increased risks for breast and ovarian cancers. Although risk-reduction strategies can be undertaken by these women, knowledge regarding the uptake of these strategies is limited. Additionally, the healthcare behaviours of women who receive inconclusive test results are not known. This study protocol describes the creation of a retrospective cohort of women who have undergone genetic testing for BRCA1 and BRCA2, linking genetic test results with administrative data to quantify the uptake of risk-reduction strategies and to assess long-term cancer and non-cancer outcomes after genetic testing. METHODS AND ANALYSIS Approximately two-thirds of BRCA1 and BRCA2 testing in Ontario, Canada is performed at North York General Hospital (NYGH) and Mount Sinai Hospital (MSH), Toronto. We will use registries at these sites to assemble a cohort of approximately 17 000 adult women who underwent BRCA1 and BRCA2 testing from January 2007 to April 2016. Trained chart abstractors will obtain detailed information for all women tested over this period, including demographics, personal and family cancer histories and genetic test results. We will link these data to provincial administrative databases, enabling assessment of healthcare utilisation and long-term outcomes after testing. Study outcomes will include the uptake of breast cancer screening and prophylactic breast and ovarian surgery, cancer incidence and mortality and incidence of non-cancer health outcomes, including cardiovascular, osteoporotic and neurodegenerative disease. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Boards at NYGH (no 16-0035), MSH (no 13-0124) and Sunnybrook Health Sciences Centre (no 275-2016). We plan to disseminate research findings through peer-reviewed publications and presentations at national and international meetings.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maria C Cusimano
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kelly Metcalfe
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Tari Little
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jordan Lerner-Ellis
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Andrea Eisen
- Sunnybrook Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Wendy S Meschino
- Department of Molecular Genetics, North York General Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Eleje GU, Eke AC, Ezebialu IU, Ikechebelu JI, Ugwu EO, Okonkwo OO. Risk-reducing bilateral salpingo-oophorectomy in women with BRCA1 or BRCA2 mutations. Cochrane Database Syst Rev 2018; 8:CD012464. [PMID: 30141832 PMCID: PMC6513554 DOI: 10.1002/14651858.cd012464.pub2] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The presence of deleterious mutations in breast cancer 1 gene (BRCA1) or breast cancer 2 gene (BRCA2) significantly increases the risk of developing some cancers, such as breast and high-grade serous cancer (HGSC) of ovarian, tubal and peritoneal origin. Risk-reducing salpingo-oophorectomy (RRSO) is usually recommended to BRCA1 or BRCA2 carriers after completion of childbearing. Despite prior systematic reviews and meta-analyses on the role of RRSO in reducing the mortality and incidence of breast, HGSC and other cancers, RRSO is still an area of debate and it is unclear whether RRSO differs in effectiveness by type of mutation carried. OBJECTIVES To assess the benefits and harms of RRSO in women with BRCA1 or BRCA2 mutations. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 7) in The Cochrane Library, MEDLINE Ovid, Embase Ovid and trial registries, with no language restrictions up to July 2017. We handsearched abstracts of scientific meetings and other relevant publications. SELECTION CRITERIA We included non-randomised trials (NRS), prospective and retrospective cohort studies, and case series that used statistical adjustment for baseline case mix using multivariable analyses comparing RRSO versus no RRSO in women without a previous or coexisting breast, ovarian or fallopian tube malignancy, in women with or without hysterectomy, and in women with a risk-reducing mastectomy (RRM) before, with or after RRSO. DATA COLLECTION AND ANALYSIS We extracted data and performed meta-analyses of hazard ratios (HR) for time-to-event variables and risk ratios (RR) for dichotomous outcomes, with 95% confidence intervals (CI). To assess bias in the studies, we used the ROBINS-I 'Risk of bias' assessment tool. We quantified inconsistency between studies by estimating the I2 statistic. We used random-effects models to calculate pooled effect estimates. MAIN RESULTS We included 10 cohort studies, comprising 8087 participants (2936 (36%) surgical participants and 5151 (64%) control participants who were BRCA1 or BRCA2 mutation carriers. All the studies compared RRSO with or without RRM versus no RRSO (surveillance). The certainty of evidence by GRADE assessment was very low due to serious risk of bias. Nine studies, including 7927 women, were included in the meta-analyses. The median follow-up period ranged from 0.5 to 27.4 years. MAIN OUTCOMES overall survival was longer with RRSO compared with no RRSO (HR 0.32, 95% CI 0.19 to 0.54; P < 0.001; 3 studies, 2548 women; very low-certainty evidence). HGSC cancer mortality (HR 0.06, 95% CI 0.02 to 0.17; I² = 69%; P < 0.0001; 3 studies, 2534 women; very low-certainty evidence) and breast cancer mortality (HR 0.58, 95% CI 0.39 to 0.88; I² = 65%; P = 0.009; 7 studies, 7198 women; very low-certainty evidence) were lower with RRSO compared with no RRSO. None of the studies reported bone fracture incidence. There was a difference in favour of RRSO compared with no RRSO in terms of ovarian cancer risk perception quality of life (MD 15.40, 95% CI 8.76 to 22.04; P < 0.00001; 1 study; very low-certainty evidence). None of the studies reported adverse events.Subgroup analyses for main outcomes: meta-analysis showed an increase in overall survival among women who had RRSO versus women without RRSO who were BRCA1 mutation carriers (HR 0.30, 95% CI 0.17 to 0.52; P < 0001; I² = 23%; 3 studies; very low-certainty evidence) and BRCA2 mutation carriers (HR 0.44, 95% CI 0.23 to 0.85; P = 0.01; I² = 0%; 2 studies; very low-certainty evidence). The meta-analysis showed a decrease in HGSC cancer mortality among women with RRSO versus no RRSO who were BRCA1 mutation carriers (HR 0.10, 95% CI 0.02 to 0.41; I² = 54%; P = 0.001; 2 studies; very low-certainty evidence), but uncertain for BRCA2 mutation carriers due to low frequency of HGSC cancer deaths in BRCA2 mutation carriers. There was a decrease in breast cancer mortality among women with RRSO versus no RRSO who were BRCA1 mutation carriers (HR 0.45, 95% CI 0.30 to 0.67; I² = 0%; P < 0.0001; 4 studies; very low-certainty evidence), but not for BRCA2 mutation carriers (HR 0.88, 95% CI 0.42 to 1.87; I² = 63%; P = 0.75; 3 studies; very low-certainty evidence). One study showed a difference in favour of RRSO versus no RRSO in improving quality of life for ovarian cancer risk perception in women who were BRCA1 mutation carriers (MD 10.70, 95% CI 2.45 to 18.95; P = 0.01; 98 women; very low-certainty evidence) and BRCA2 mutation carriers (MD 13.00, 95% CI 3.59 to 22.41; P = 0.007; very low-certainty evidence). Data from one study showed a difference in favour of RRSO and RRM versus no RRSO in increasing overall survival (HR 0.14, 95% CI 0.02 to 0.98; P = 0.0001; I² = 0%; low-certainty evidence), but no difference for breast cancer mortality (HR 0.78, 95% CI 0.51 to 1.19; P = 0.25; very low-certainty evidence). The risk estimates for breast cancer mortality according to age at RRSO (50 years of age or less versus more than 50 years) was not protective and did not differ for BRCA1 (HR 0.85, 95% CI 0.64 to 1.11; I² = 16%; P = 0.23; very low-certainty evidence) and BRCA2 carriers (HR 0.88, 95% CI 0.42 to 1.87; I² = 63%; P = 0.75; very low-certainty evidence). AUTHORS' CONCLUSIONS There is very low-certainty evidence that RRSO may increase overall survival and lower HGSC and breast cancer mortality for BRCA1 and BRCA2 carriers. Very low-certainty evidence suggests that RRSO reduces the risk of death from HGSC and breast cancer in women with BRCA1 mutations. Evidence for the effect of RRSO on HGSC and breast cancer in BRCA2 carriers was very uncertain due to low numbers. These results should be interpreted with caution due to questionable study designs, risk of bias profiles, and very low-certainty evidence. We cannot draw any conclusions regarding bone fracture incidence, quality of life, or severe adverse events for RRSO, or for effects of RRSO based on type and age at risk-reducing surgery. Further research on these outcomes is warranted to explore differential effects for BRCA1 or BRCA2 mutations.
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Affiliation(s)
- George U Eleje
- Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi CampusEffective Care Research Unit, Department of Obstetrics and GynaecologyPMB 5001, NnewiNigeria
| | - Ahizechukwu C Eke
- Johns Hopkins University School of MedicineDivision of Maternal Fetal Medicine, Department of Gynecology and Obstetrics600 N Wolfe StreetPhipps 228BaltimoreUSA21287‐1228
| | - Ifeanyichukwu U Ezebialu
- Faculty of Clinical medicine, College of Medicine, Anambra State University AmakuDepartment of Obstetrics and GynaecologyAwkaNigeria
| | - Joseph I Ikechebelu
- Nnamdi Azikiwe University Teaching HospitalDepartment of Obstetrics/GynaecologyNnewiNigeria
| | - Emmanuel O Ugwu
- University of Nigeria Enugu Campus/University of Nigeria Teaching Hospital Ituko‐OzallaObstetrics and GynaecologyEnuguNigeria400001
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Arts-de Jong M, DeJong CAJ, Hermens RP, Kissane DW, Massuger LM, Hoogerbrugge N, Prins JB, deHullu JA. High demoralization in a minority of oophorectomized BRCA1/2 mutation carriers influences quality of life. J Psychosom Obstet Gynaecol 2018; 39:96-104. [PMID: 28279121 DOI: 10.1080/0167482x.2017.1296429] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Demoralization is a relatively neglected issue in which low morale and poor coping result from a stressor such as familial cancer risk. Female BRCA1/2 mutation carriers are highly susceptible for developing breast and ovarian cancer. The aim of this study was to evaluate demoralization in oophorectomized BRCA1/2 mutation carriers and its relation to quality of life. METHODS This cross-sectional study examined 288 oophorectomized BRCA1/2 mutation carriers using the following standardized self-report measures: Demoralization Scale, EORTC Quality of Life Questionnaire-C30, State-Trait Anxiety Inventory and the Cancer Worry Scale. RESULTS The mean score on the Demoralization Scale was 17.8 (SD 14.0). A clinically significant level of demoralization, defined as a score ≥30, was found in 45 BRCA1/2 mutation carriers (16%). Being highly demoralized was associated with a significantly lower quality of life, and higher levels of physical problems, anxiety and cancer worries. No demographic or clinical factors could predict higher levels of demoralization. CONCLUSIONS Our findings established that a clear proportion of oophorectomized BRCA1/2 mutation carriers experience demoralization impacting on their well-being. Further research is needed to explore the natural trajectory of demoralization and the resultant need for support in these women.
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Affiliation(s)
- Marieke Arts-de Jong
- a Department of Obstetrics and Gynaecology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Cor A J DeJong
- b Nijmegen Institute for Scientist-Practitioners in Addiction, Radboud University Nijmegen , Nijmegen , The Netherlands
| | - Rosella P Hermens
- c Scientific Institute for Quality of Health Care, Radboud University Medical Center , Nijmegen , The Netherlands
| | - David W Kissane
- d Department of Psychiatry, School of Clinical Sciences at Monash Health , Monash University , Clayton , Victoria , Australia
| | - Leon M Massuger
- a Department of Obstetrics and Gynaecology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Nicoline Hoogerbrugge
- e Department of Human Genetics , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Judith B Prins
- f Department of Medical Psychology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Joanne A deHullu
- a Department of Obstetrics and Gynaecology , Radboud University Medical Center , Nijmegen , The Netherlands
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van Verschuer VMT, Mureau MAM, Heemskerk-Gerritsen BAM, Gadjradj PS, Rogier C, Verhoef C, Gopie JP, Seynaeve C, Koppert LB. Long-term outcomes of bilateral direct-to-implant breast reconstruction in women at high breast cancer risk. J Plast Surg Hand Surg 2018; 52:245-252. [PMID: 29806795 DOI: 10.1080/2000656x.2018.1476364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Challenges of direct-to-implant breast reconstruction (BR) are to achieve sufficient implant coverage and lower pole projection. We assessed reoperation rates, long-term patient satisfaction and aesthetic outcome after direct-to-implant BR without acellular dermal matrix (ADM) in women with high breast cancer risk. METHODS Women who underwent bilateral skin or nipple-sparing mastectomy and immediate direct-to-implant BR between 1994 and 2006 completed a survey on reoperations and the Breast-Q Reconstruction questionnaire. Photographs taken during follow-up were rated for long-term aesthetic outcome (scale 1-10) by five plastic surgeons. Outcomes were compared between women who never underwent unanticipated reoperations after immediate BR and women who underwent one or more reoperations, adjusted for potential confounders using multivariable linear regression. RESULTS Of 143 women, 70 (49%) were never reoperated and 73 (51%) had undergone reoperations. Median follow-up was 12 years in both groups (range 7-17 and 6-19 years, respectively). Baseline characteristics were comparable except for history of prophylactic oophorectomy with 81% in the no-reoperations group versus 66% in the reoperated group (p = .03). Breast-Q scores were 59.7 ± 17.3 versus 58.0 ± 17.8 (p = .67) for 'satisfaction with breasts' and 71.1 ± 20.3 versus 68.1 ± 22.9 (p = .47) for 'satisfaction with outcome' in the no-reoperation versus reoperation group, respectively. Aesthetic outcome was scored 5.8 ± 1.1 in the no-reoperation group versus 5.3 ± 1.3 in the reoperation group (p = .01). CONCLUSIONS The single-stage intent did not prevent unanticipated surgical reinterventions in 51% of the patients. Long-term patient satisfaction was reasonable and not affected by reoperations. Aesthetic outcome, however, was only poor to reasonable and scores were significantly lower in the reoperated group.
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Affiliation(s)
- Victorien M T van Verschuer
- a Department of Surgical Oncology , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
| | - Marc A M Mureau
- b Department of Plastic and Reconstructive Surgery , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
| | | | - Pravesh S Gadjradj
- a Department of Surgical Oncology , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
| | - Cleo Rogier
- a Department of Surgical Oncology , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
| | - Cornelis Verhoef
- a Department of Surgical Oncology , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
| | - Jessica P Gopie
- d Center for Human and Clinical Genetics, Leiden University Medical Center , Leiden , the Netherlands
| | - Caroline Seynaeve
- c Department of Medical Oncology , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
| | - Linetta B Koppert
- a Department of Surgical Oncology , Erasmus MC Cancer Institute, University Medical Center Rotterdam , Rotterdam , the Netherlands
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Woitek R, Pfeiler G, Farr A, Kapetas P, Furtner J, Bernathova M, Schöpf V, Clauser P, Marino MA, Pinker K, Baltzer PA, Helbich TH. MRI-based quantification of residual fibroglandular tissue of the breast after conservative mastectomies. Eur J Radiol 2018; 104:1-7. [PMID: 29857853 DOI: 10.1016/j.ejrad.2018.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Skin-sparing and nipple-sparing mastectomies (SSM; NSM) remove the breast's fibroglandular tissue (FGT), thereby reducing breast cancer risk. The postoperative presence of residual FGT (RFGT) is associated with remaining cancer risk. This study evaluated the role of MRI in the quantitative assessment of RFGT and its impact on the estimation of the remaining breast cancer risk. METHODS The postoperative MRI scans (following EUSOMA recommendations) of 58 patients who had undergone SSM or NSM between 2003 and 2013, as well as preoperative MRI scans that were available in 25 of these patients, were retrospectively evaluated for the presence and location of RFGT by three radiologists. Two different observers quantitatively assessed the volume and percentage of retromamillary and other RFGT (RFGTrm and RFGTother) were assessed. The Fisher's exact test, the Student's t-test, and intraclass coherence were used to compare patient groups and to assess reproducibility. RESULTS RFGT was found in 20% of all breasts and significantly more frequently after NSM than SSM (50% vs. 13%, p = .003). RFGTrm and RFGTother were more prevalent after NSM (p < 0.001; p = .127). RFGT ranged from 0.5 to 26% of the preoperative FGT, with higher percentages after NSM than SSM (p = .181). CONCLUSIONS The prevalence and percentage of RFGT found on MRI indicate a considerable remaining postoperative breast cancer risk in some women.
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Affiliation(s)
- Ramona Woitek
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Georg Pfeiler
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Alex Farr
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Panagiotis Kapetas
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Julia Furtner
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Maria Bernathova
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | | | - Paola Clauser
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Maria A Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, Policlinico Universitario G. Martino, University of Messina, Messina, Italy
| | - Katja Pinker
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria; Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Pascal A Baltzer
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Thomas H Helbich
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria.
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Carbine NE, Lostumbo L, Wallace J, Ko H. Risk-reducing mastectomy for the prevention of primary breast cancer. Cochrane Database Syst Rev 2018; 4:CD002748. [PMID: 29620792 PMCID: PMC6494635 DOI: 10.1002/14651858.cd002748.pub4] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010. OBJECTIVES (i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH METHODS For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English. SELECTION CRITERIA Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer. DATA COLLECTION AND ANALYSIS At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias. MAIN RESULTS All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM. AUTHORS' CONCLUSIONS While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.
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Affiliation(s)
- Nora E Carbine
- Georgetown University Lombardi Cancer CenterTranslational Breast Cancer Research Consortium (TBCRC)WashingtonD.C.USA20007
| | | | | | - Henry Ko
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation Building92‐94 Parramatta Rd.,CamperdownNSWAustralia2050
- Academic Medicine Research Institute, Duke‐NUS Graduate Medical SchoolCentre for Health Services Research, SingHealthSingaporeSingapore169857
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Yoshimura A, Okumura S, Sawaki M, Hattori M, Ishiguro J, Adachi Y, Kotani H, Gondo N, Kataoka A, Iwase M, Onishi S, Sugino K, Terada M, Horisawa N, Mori M, Takaiso N, Hyodo I, Iwata H. Feasibility study of contralateral risk-reducing mastectomy with breast reconstruction for breast cancer patients with BRCA mutations in Japan. Breast Cancer 2018. [PMID: 29520501 DOI: 10.1007/s12282-018-0850-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Contralateral risk-reducing mastectomy (CRRM) for breast cancer patients with BRCA mutations has been reported to not only reduce breast cancer incidence but also to improve survival. The National Comprehensive Cancer Network guidelines recommend providing CRRM to women with BRCA mutations who desire CRRM after risk-reduction counseling. However, in Japan, CRRM cannot be performed generally because it is not covered by health insurance. Thus, we conducted a feasibility study to confirm the safety of CRRM. METHODS CRRM with bilateral breast reconstructions were performed for breast cancer patients with BRCA mutations. The primary endpoint was early adverse events within 3 months, and secondary endpoints were late adverse events. RESULTS Between August 2014 and November 2016, ten patients were enrolled. The median age was 37.5 years, and five of the patients had the BRCA1 mutation while five had the BRCA2 mutation. Six patients received neoadjuvant chemotherapy. Eight patients selected silicone breast implants, and two patients selected transverse rectus abdominis myocutaneous flap reconstruction. Pathological findings showed no evidence of occult breast cancers in any of the patients. At a median of 25.5 months follow-up time, CRRM-related early adverse events were hematoma (subsequently removed by re-operation; grade 2, n = 1), wound infection (grade 2, n = 1), skin ulceration (grade 1, n = 2) and wound pain (grade 1, n = 1). Overall, there were no grade 3 or more severe adverse events. CONCLUSION Our results confirm that CRRM with reconstruction could be performed safely.
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Affiliation(s)
- Akiyo Yoshimura
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan.
| | - Seiko Okumura
- Department of Plastic and Reconstructive Surgery, Aichi Cancer Hospital, Nagoya, Japan
| | - Masataka Sawaki
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Masaya Hattori
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Junko Ishiguro
- Division of Molecular Medicine, Aichi Cancer Center Research Institute, Nagoya, Japan
| | - Yayoi Adachi
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Haruru Kotani
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Naomi Gondo
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Ayumi Kataoka
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Madoka Iwase
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Sakura Onishi
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Kayoko Sugino
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Mitsuo Terada
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nanae Horisawa
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Makiko Mori
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Nobue Takaiso
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Ikuo Hyodo
- Department of Plastic and Reconstructive Surgery, Aichi Cancer Hospital, Nagoya, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
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