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Rodriguez NJ, Furniss CS, Yurgelun MB, Ukaegbu C, Constantinou PE, Fortes I, Caruso A, Schwartz AN, Stopfer JE, Underhill-Blazey M, Kenner B, Nelson SH, Okumura S, Zhou AY, Coffin TB, Uno H, Horiguchi M, Ocean AJ, McAllister F, Lowy AM, Klein AP, Madlensky L, Petersen GM, Garber JE, Lippman SM, Goggins MG, Maitra A, Syngal S. A Randomized Trial of Two Remote Health Care Delivery Models on the Uptake of Genetic Testing and Impact on Patient-Reported Psychological Outcomes in Families With Pancreatic Cancer: The Genetic Education, Risk Assessment, and Testing (GENERATE) Study. Gastroenterology 2024; 166:872-885.e2. [PMID: 38320723 PMCID: PMC11034726 DOI: 10.1053/j.gastro.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND & AIMS Genetic testing uptake for cancer susceptibility in family members of patients with cancer is suboptimal. Among relatives of patients with pancreatic ductal adenocarcinoma (PDAC), The GENetic Education, Risk Assessment, and TEsting (GENERATE) study evaluated 2 online genetic education/testing delivery models and their impact on patient-reported psychological outcomes. METHODS Eligible participants had ≥1 first-degree relative with PDAC, or ≥1 first-/second-degree relative with PDAC with a known pathogenic germline variant in 1 of 13 PDAC predisposition genes. Participants were randomized by family, between May 8, 2019, and June 1, 2021. Arm 1 participants underwent a remote interactive telemedicine session and online genetic education. Arm 2 participants were offered online genetic education only. All participants were offered germline testing. The primary outcome was genetic testing uptake, compared by permutation tests and mixed-effects logistic regression models. We hypothesized that Arm 1 participants would have a higher genetic testing uptake than Arm 2. Validated surveys were administered to assess patient-reported anxiety, depression, and cancer worry at baseline and 3 months postintervention. RESULTS A total of 424 families were randomized, including 601 participants (n = 296 Arm 1; n = 305 Arm 2), 90% of whom completed genetic testing (Arm 1 [87%]; Arm 2 [93%], P = .014). Arm 1 participants were significantly less likely to complete genetic testing compared with Arm 2 participants (adjusted ratio [Arm1/Arm2] 0.90, 95% confidence interval 0.78-0.98). Among participants who completed patient-reported psychological outcomes questionnaires (Arm 1 [n = 194]; Arm 2 [n = 206]), the intervention did not affect mean anxiety, depression, or cancer worry scores. CONCLUSIONS Remote genetic education and testing can be a successful and complementary option for delivering genetics care. (Clinicaltrials.gov, number NCT03762590).
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Affiliation(s)
- Nicolette J Rodriguez
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - C Sloane Furniss
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Matthew B Yurgelun
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Chinedu Ukaegbu
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Pamela E Constantinou
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | | | | | | | | | | | - Scott H Nelson
- Pancreatic Cancer Action Network Volunteer, Patient Advocate, and Pancreatic Cancer Survivor
| | | | | | - Tara B Coffin
- WIRB-Copernicus Group Institutional Review Board, Puyallup, Washington
| | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Miki Horiguchi
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Florencia McAllister
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Andrew M Lowy
- Moores Cancer Center, UC San Diego, San Diego, California
| | - Alison P Klein
- Johns Hopkins University, Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Lisa Madlensky
- Moores Cancer Center, UC San Diego, San Diego, California
| | | | - Judy E Garber
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Michael G Goggins
- Johns Hopkins University, Sol Goldman Pancreatic Cancer Research Center, Baltimore, Maryland
| | - Anirban Maitra
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts.
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Tanaka A, Matsumoto M, Takao M, Miura S, Hasegawa Y, Otsubo R, Hayashi H, Isomoto I, Miura K, Nagayasu T. Simultaneous bilateral mastectomy and RRSO for BRCA2-positive non-invasive breast cancer in Japan: a case report and analysis of initial experience. Hered Cancer Clin Pract 2023; 21:23. [PMID: 37957733 PMCID: PMC10644634 DOI: 10.1186/s13053-023-00268-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/06/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND In Japan, genetic testing, surveillance, and risk-reducing surgery for hereditary breast and ovarian cancer (HBOC) syndrome have been covered by the Japanese national insurance system since April 2020. On the other hand, the current situation is that medical care, including surveillance of undiagnosed (cancer-free) patients, is self-funded even for individuals with HBOC. We report a case in which breast cancer was diagnosed at an early stage during surveillance for cancer-free HBOC at the patient's own expense, and risk-reducing surgery was performed at the same time as treatment for breast cancer. CASE PRESENTATION The patient was a 63-year-old woman. Her sister had a history of breast cancer in her 30s and was found to be a BRCA2 pathogenic variant carrier by genetic testing. The patient therefore presented to the genetic department of our hospital and underwent genetic testing (out-of-pocket). A pathogenic variant was found at the same site. During annual breast and ovarian surveillance at the patient's own expense, a physician with sufficient expertise in contrast-enhanced breast magnetic resonance imaging (MRI) noticed a change in the contrast enhancement pattern on breast MRI and performed needle biopsy, revealing ductal carcinoma in situ. At the request of the patient, she underwent concurrent contralateral risk-reducing mastectomy and risk-reducing salpingo-oophorectomy in addition to breast cancer treatment. CONCLUSIONS We encountered a case in which cancer treatment and risk-reducing surgery were performed at the same time for a pathogenic variant carrier who was very anxious about developing cancer. Surveillance of cancer-free BRCA1/2 mutation carriers and expansion of insurance coverage for surgery are important future issues.
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Affiliation(s)
- Aya Tanaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
- Genetic Counseling Unit, Clinical Genomics Center, Nagasaki University Hospital, Nagasaki, Japan.
| | - Megumi Matsumoto
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Genetic Counseling Unit, Clinical Genomics Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Mami Takao
- Genetic Counseling Unit, Clinical Genomics Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Shoko Miura
- Genetic Counseling Unit, Clinical Genomics Center, Nagasaki University Hospital, Nagasaki, Japan
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuri Hasegawa
- Genetic Counseling Unit, Clinical Genomics Center, Nagasaki University Hospital, Nagasaki, Japan
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryota Otsubo
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroko Hayashi
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Pathology, Sasebo City General Hospital, Nagasaki, Japan
| | - Ichiro Isomoto
- Department of Radiology, St. Francis Hospital, Nagasaki, Japan
| | - Kiyonori Miura
- Genetic Counseling Unit, Clinical Genomics Center, Nagasaki University Hospital, Nagasaki, Japan
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Khan SA, Hernandez-Villafuerte K, Hernandez D, Schlander M. Estimation of the stage-wise costs of breast cancer in Germany using a modeling approach. Front Public Health 2023; 10:946544. [PMID: 36684975 PMCID: PMC9853539 DOI: 10.3389/fpubh.2022.946544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
Breast cancer (BC) is a heterogeneous disease representing a substantial economic burden. In order to develop policies that successfully decrease this burden, the factors affecting costs need to be fully understood. Evidence suggests that early-stage BC has a lower cost than a late stage BC. We aim to provide conservative estimates of BC's stage-wise medical costs from German healthcare and the payer's perspective. To this end, we conducted a literature review of articles evaluating stage-wise costs of BC in Germany through PubMed, Web of Science, and Econ Lit databases supplemented by Google Scholar. We developed a decision tree model to estimate BC-related medical costs in Germany using available treatment and cost information. The review generated seven studies; none estimated the stage-wise costs of BC. The studies were classified into two groups: case scenarios (five studies) and two studies based on administrative data. The first sickness funds data study (Gruber et al., 2012) used information from the year 1999 to approach BC attributable cost; their results suggest a range between €3,929 and €11,787 depending on age. The second study (Kreis, Plöthner et al., 2020) used 2011-2014 data and suggested an initial phase incremental cost of €21,499, an intermediate phase cost of €2,620, and a terminal phase cost of €34,513 per incident case. Our decision tree model-based BC stage-wise cost estimates were €21,523 for stage I, €25,679 for stage II, €30,156 for stage III, and €42,086 for stage IV. Alternatively, the modeled cost estimates are €20,284 for the initial phase of care, €851 for the intermediate phase of care, and €34,963 for the terminal phase of care. Our estimates for phases of care are consistent with recent German estimates provided by Kreis et al. Furthermore, the data collected by sickness funds are collected primarily for reimbursement purposes, where the German ICD-10 classification system defines a cancer diagnosis. As a result, claims data lack the clinical information necessary to understand stage-wise BC costs. Our model-based estimates fill the gap and inform future economic evaluations of BC interventions.
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Affiliation(s)
- Shah Alam Khan
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Diego Hernandez
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Faculty of Economics and Social Sciences, Alfred Weber Institute (AWI), University of Heidelberg, Heidelberg, Germany
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Bommer C, Lupatsch J, Bürki N, Schwenkglenks M. Cost-utility analysis of risk-reducing strategies to prevent breast and ovarian cancer in BRCA-mutation carriers in Switzerland. Eur J Health Econ 2022; 23:807-821. [PMID: 34767113 PMCID: PMC9170622 DOI: 10.1007/s10198-021-01396-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 10/21/2021] [Indexed: 05/02/2023]
Abstract
OBJECTIVE We aimed to identify the most cost-effective of all prophylactic measures available in Switzerland for women not yet affected by breast and ovarian cancer who tested positive for a BRCA1/2 mutation. METHODS Prophylactic bilateral mastectomy (PBM), salpingo-oophorectomy (PBSO), combined PBM&PBSO and chemoprevention (CP) initiated at age 40 years were compared with intensified surveillance (IS). A Markov model with a life-long time horizon was developed from the perspective of the Swiss healthcare system using mainly literature-derived data to evaluate costs, quality-adjusted life years (QALYs) and survival. Costs and QALYs were discounted by 3% per year. Robustness of the results was tested with deterministic and probabilistic sensitivity analyses. RESULTS All prophylactic measures were found to be cost-saving with an increase in QALYs and life years (LYs) compared to IS. PBM&PBSO were found to be most cost-effective and dominated all other strategies in women with a BRCA1 or BRCA2 mutation. Lifetime costs averaged to 141,293 EUR and 14.5 QALYs per woman with a BRCA1 mutation under IS, versus 76,639 EUR and 19.2 QALYs for PBM&PBSO. Corresponding results for IS per woman with a BRCA2 mutation were 102,245 EUR and 15.5 QALYs, versus 60,770 EUR and 19.9 QALYs for PBM&PBSO. The results were found to be robust in sensitivity analysis; no change in the dominant strategy for either BRCA-mutation was observed. CONCLUSION All more invasive strategies were found to increase life expectancy and quality of life of women with a BRCA1 or BRCA2 mutation and were cost-saving for the Swiss healthcare system compared to IS.
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Affiliation(s)
- Claudine Bommer
- University of Zurich, Zürich, Switzerland.
- Department of Gynaecological Oncology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Judith Lupatsch
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - Nicole Bürki
- Gynaecological Tumor Center, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
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Carbonara N, La Forgia D, Pellegrino R, Ressa C, Tommasi S. A Cost Decision Model Supporting Treatment Strategy Selection in BRCA1/2 Mutation Carriers in Breast Cancer. J Pers Med 2021; 11:847. [PMID: 34575624 DOI: 10.3390/jpm11090847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 01/08/2023] Open
Abstract
In this paper, a cost decision-making model that compares the healthcare costs for diverse treatment strategies is built for BRCA-mutated women with breast cancer. Moreover, this model calculates the cancer treatment costs that could potentially be prevented, if the treatment strategy with the lowest total cost, along the entire lifetime of the patient, is chosen for high-risk women with breast cancer. The benchmark of the healthcare costs for diverse treatment strategies is selected in the presence of uncertainty, i.e., considering, throughout the lifetime of the patient, the risks and complications that may arise in each strategy and, therefore, the costs associated with the management of such events. Our results reveal a clear economic advantage of adopting the cost decision-making model for benchmarking the healthcare costs for various treatment strategies for BRCA-mutated women with breast cancer. The cost savings were higher when all breast cancer patients underwent counseling and genetic testing before deciding on any diagnostic-therapeutic path, with a probability of obtaining savings of over 75%.
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Char SN, Bloom JA, DeMarco D, Chatterjee A. Evaluating the Quality of Cost-Effectiveness Literature in Breast Surgery: What Do We Do Well and How Can We Do Better? A Systematic Review. Am Surg 2021; 88:2660-2669. [PMID: 33861654 DOI: 10.1177/00031348211011148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgical options for breast cancer are numerous and span multiple surgical disciplines. Decision analyses aid surgeons in making the most cost-effective choice, thus reducing health care expenditure while maximizing patient outcome. In this study, we aimed to evaluate existing breast surgery cost-effectiveness literature against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) validated scoring system. METHODS A PRISMA search was performed for cost-effectiveness within breast surgery. Articles were scored with CHEERS criteria on a 0-24 scale and qualitative data were collected. Subgroup analysis was performed comparing pre-CHEERS (published in 2013 or earlier) and post-CHEERS (published in 2014 or later) cohorts. Chi-squared analysis was performed to compare where studies lost points between cohorts. RESULTS Of 2279 articles screened, 46 articles were included. The average CHEERS score was 18.18. Points were most often lost for characterizing heterogeneity, followed by discount rate, incremental costs and outcomes, and abstract. Quality-adjusted life year was the most commonly used health outcome, with visual model or analog scales as the most commonly used measure of effectiveness obtained primarily from surgeons or physicians. Most articles characterized uncertainty by deterministic sensitivity analysis, followed by both deterministic and probabilistic, then probabilistic. Average CHEERS scores were similar between pre- and post-CHEERS cohorts (17.67 vs. 18.40, P > .05) There were several significant differences in where articles lost points between pre- and post-CHEERS cohorts. DISCUSSION In order to standardize the reporting of results, cost-effectiveness studies in breast surgery should adhere to the current CHEERS criteria and aim to better characterize heterogeneity in their analyses.
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Affiliation(s)
- Sydney N Char
- 12261Tufts University School of Medicine, Boston, MA, USA
| | - Joshua A Bloom
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Danielle DeMarco
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
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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] [What about the content of this article? (0)] [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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Meier F, Harney A, Rhiem K, Neusser S, Neumann A, Braun M, Wasem J, Huster S, Dabrock P, Schmutzler RK. Risk-Adjusted Prevention. Perspectives on the Governance of Entitlements to Benefits in the Case of Genetic (Breast Cancer) Risks. Recent Results Cancer Res 2021; 218:47-66. [PMID: 34019162 DOI: 10.1007/978-3-030-63749-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article is a revised version of our proposal for the establishment of the legal concept of risk-adjusted prevention in the German healthcare system to regulate access to risk-reduction measures for persons at high and moderate genetic cancer risk (Meier et al. Risikoadaptierte Prävention'. Governance Perspective für Leistungsansprüche bei genetischen (Brustkrebs-)Risiken, Springer, Wiesbaden, 2018). The German context specifics are summarized to enable the source text to be used for other country-specific healthcare systems. Establishing such a legal concept is relevant to all universal and free healthcare systems similar to Germany's. Disease risks can be determined with increasing precision using bioinformatics and biostatistical innovations ('big data'), due to the identification of pathogenic germ line mutations in cancer risk genes as well as non-genetic factors and their interactions. These new technologies open up opportunities to adapt therapeutic and preventive measures to the individual risk profile of complex diseases in a way that was previously unknown, enabling not only adequate treatment but in the best case, prevention. Access to risk-reduction measures for carriers of genetic risks is generally not regulated in healthcare systems that guarantee universal and equal access to healthcare benefits. In many countries, including Austria, Denmark, the UK and the US, entitlement to benefits is essentially linked to the treatment of already manifest disease. Issues around claiming benefits for prophylactic measures involve not only evaluation of clinical options (genetic diagnostics, chemoprevention, risk-reduction surgery), but the financial cost and-from a social ethics perspective-the relationship between them. Section 1 of this chapter uses the specific example of hereditary breast cancer to show why from a medical, social-legal, health-economic and socio-ethical perspective, regulated entitlement to benefits is necessary for persons at high and moderate risk of cancer. Section 2 discusses the medical needs of persons with genetic cancer risks and goes on to develop the healthy sick model which is able to integrate the problems of the different disciplines into one scheme and to establish criteria for the legal acknowledgement of persons at high and moderate (breast cancer) risks. In the German context, the social-legal categories of classical therapeutic medicine do not adequately represent preventive measures as a regular service within the healthcare system. We propose risk-adjusted prevention as a new legal concept based on the heuristic healthy sick model. This category can serve as a legal framework for social law regulation in the case of persons with genetic cancer risks. Risk-adjusted prevention can be established in principle in any healthcare system. Criteria are also developed in relation to risk collectives and allocation (Sects. 3, 4, 5).
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Affiliation(s)
- Friedhelm Meier
- Systematic Theology II (Ethics), University of Tübingen, Liebermeisterstraße 12, 72076, Tübingen, Germany.
| | - Anke Harney
- Medical Faculty, Institute for Social and Health Law, University of Bochum, Bochum, Germany
| | - Kerstin Rhiem
- Center for Hereditary Breast and Ovarian Cancer and Center for Integrated Oncology (CIO), University Hospital Cologne, Cologne, Germany
| | - Silke Neusser
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Anja Neumann
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Matthias Braun
- Systematic Theology II (Ethics), University of Erlangen-Nuremberg, Erlangen-Nuremberg, Germany
| | - Jürgen Wasem
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Stefan Huster
- Medical Faculty, Institute for Social and Health Law, University of Bochum, Bochum, Germany
| | - Peter Dabrock
- Systematic Theology II (Ethics), University of Erlangen-Nuremberg, Erlangen-Nuremberg, Germany
| | - Rita Katharina Schmutzler
- Center for Hereditary Breast and Ovarian Cancer and Center for Integrated Oncology (CIO), University Hospital Cologne, Cologne, Germany
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Stanisz M, Panczyk M, Kurzawa R, Grochans E. The Effect of Prophylactic Adnexectomy on the Quality of Life and Psychosocial Functioning of Women with the BRCA1/BRCA2 Mutations. Int J Environ Res Public Health 2019; 16:ijerph16244995. [PMID: 31818005 PMCID: PMC6950418 DOI: 10.3390/ijerph16244995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022]
Abstract
The main purpose of this study was to analyze the effect of risk-reducing salpingo-oophorectomy (RRSO) on the quality of life (QoL) and psychosocial functioning of patients with the BRCA1/BRCA2 mutations. This survey-based study was conducted using the Blatt-Kupperman Index, the Women’s Health Questionnaire, the Perceived Stress Scale, the State-Trait Anxiety Inventory, the Beck Depression Inventory-II, and the authors’ questionnaire. All calculations were done using Statistica 13.3. The QoL after RRSO was statistically significantly lower in most domains compared with the state before surgery. The greatest decline in the QoL was observed in the vasomotor symptoms domain (d = 0.953) and the smallest in the memory/concentration domain (d = 0.167). We observed a statistically significant decrease in the level of anxiety as a state (d = 0.381), as well as a statistically significant increase in the severity of climacteric symptoms (d = 0.315) and depressive symptoms (d = 0.125). Prophylactic surgeries of the reproductive organs have a negative effect on the QoL and psychosocial functioning of women with the BRCA1/2 mutations, as they increase the severity of depressive and climacteric symptoms. At the same time, these surgeries reduce anxiety as a state, which may be associated with the elimination of cancerophobia.
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Affiliation(s)
- Marta Stanisz
- Department of Gynecology and Reproductive Health, Pomeranian Medical University in Szczecin, 71-210 Szczecin, Poland; (M.S.); (R.K.)
| | - Mariusz Panczyk
- Department of Education and Research in Health Sciences, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Rafał Kurzawa
- Department of Gynecology and Reproductive Health, Pomeranian Medical University in Szczecin, 71-210 Szczecin, Poland; (M.S.); (R.K.)
- Center of Gynecology and Treatmemt for Infertility “Vitrolive”, al. Wojska Polskiego 103, 70-483 Szczecin, Poland
| | - Elżbieta Grochans
- Department of Nursing, Pomeranian Medical University in Szczecin; ul. Żołnierska 48, 71-210 Szczecin, Poland
- Correspondence: ; Tel.: +48-91-4800-910
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Jayasekera J, Mandelblatt JS. Systematic Review of the Cost Effectiveness of Breast Cancer Prevention, Screening, and Treatment Interventions. J Clin Oncol 2019; 38:332-350. [PMID: 31804858 DOI: 10.1200/jco.19.01525] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jinani Jayasekera
- Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Jeanne S Mandelblatt
- Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
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Ball S, Arevalo M, Juarez E, Payne JD, Jones C. Breast cancer chemoprevention: An update on current practice and opportunities for primary care physicians. Prev Med 2019; 129:105834. [PMID: 31494144 DOI: 10.1016/j.ypmed.2019.105834] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
Abstract
Several risk assessment models have been validated for the estimation of risk of breast cancer in women. Chemoprevention through hormonal therapy is an effective way to reduce the incidence of breast cancer in women with high risk. Selective estrogen receptor modulators, tamoxifen and raloxifene, are approved for this indication by the United States Food and Drug Administration, and aromatase inhibitors have also shown promise in recent studies. These medications are generally well tolerated, except for reported increased rates of fractures and venous thromboembolic events. Despite strong recommendations from several regulatory bodies, advocacy for chemoprevention has been inadequate in practice, more so among the primary care physicians. Studies have identified several barriers in physicians, patients, and the system, contributing to this problem. Lack of knowledge about risk assessment models and chemoprevention options preclude physicians from prescribing these medications with confidence. Fear of potential adverse events, confusion regarding the purpose of the therapy, and need for continued adherence for five years are among the principal reasons for reduced chemoprevention uptake and early discontinuation among patients. Multifaceted interventions directed at education and training of health care professionals, proper counseling of women at high risk, and promotion of the development of improved medications might help ensure better chemoprevention uptake in the target population.
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Affiliation(s)
- Somedeb Ball
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Meily Arevalo
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Edna Juarez
- Department of Internal Medicine, Memorial Medical Center, Las Cruces, NM, USA
| | - J Drew Payne
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Catherine Jones
- Division of Hematology and Medical Oncology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Neusser S, Lux B, Barth C, Pahmeier K, Rhiem K, Schmutzler R, Engel C, Wasem J, Huster S, Dabrock P, Neumann A. The budgetary impact of genetic testing for hereditary breast cancer for the statutory health insurance. Curr Med Res Opin 2019; 35:2103-2110. [PMID: 31394049 DOI: 10.1080/03007995.2019.1654689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: Potential opportunities and challenges of predictive genetic risk classification of healthy persons are currently discussed. However, the budgetary impact of rising demand is uncertain. This project aims to evaluate budgetary consequences of predictive genetic risk classification for statutory health insurance in Germany.Methods: A Markov model was developed in the form of a cohort simulation. It analyzes a population of female relatives of hereditary breast cancer patients. Mutation carriers are offered intensified screening, women with a BRCA1 or BRCA2 mutation can decide on prophylactic mastectomy and/or ovarectomy. The model considers the following scenarios: (a) steady demand for predictive genetic testing, and (b) rising demand. Most input parameters are based on data of the German Consortium for Hereditary Breast and Ovarian Cancer. The model contains 49 health states, starts in 2015, and runs for 10 years. Prices were evaluated from the perspective of statutory health insurance.Results: Steady demand leads to an expenditure of €49.8 million during the 10-year period. Rising demands lead to additional expenses of €125.5 million. The model reveals the genetic analysis to be the main cost driver while cost savings in treatment costs of breast and ovarian cancer are indicated.Conclusions: The results contribute to close the knowledge gap concerning the budgetary consequences due to genetic risk classification. A rising demand leads to additional costs especially due to costs for genetic analysis. The model indicates budget shifts with cost savings due to breast and ovarian cancer treatment in the scenario of rising demands.
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Affiliation(s)
- Silke Neusser
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Beate Lux
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Cordula Barth
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Kathrin Pahmeier
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Kerstin Rhiem
- Center for Hereditary Breast and Ovarian Cancer and Center for Integrated Oncology (CIO), Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Rita Schmutzler
- Center for Hereditary Breast and Ovarian Cancer and Center for Integrated Oncology (CIO), Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Jürgen Wasem
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Stefan Huster
- Faculty of Law, Lehrstuhl für Öffentliches Recht, Sozial- und Gesundheitsrecht und Rechtsphilosophie, Ruhr-Universität Bochum, Bochum, Germany
| | - Peter Dabrock
- Institute for Systematic Theology, Chair of Systematic Theology II (Ethics), Friedrich-Alexander University, Nürnberg-Erlangen, Germany
| | - Anja Neumann
- Institute for Healthcare Management and Research, University of Duisburg-Essen, Essen, Germany
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Schrauder MG, Brunel-Geuder L, Häberle L, Wunderle M, Hoyer J, Csorba R, Reis A, Schulz-Wendtland R, Beckmann MW, Lux MP. Cost effectiveness of bilateral risk-reducing mastectomy and salpingo-oophorectomy. Eur J Med Res 2019; 24:32. [PMID: 31521205 PMCID: PMC6744699 DOI: 10.1186/s40001-019-0391-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 09/03/2019] [Indexed: 11/23/2022] Open
Abstract
Background Growing demand for risk-reducing surgery in individuals with inherited susceptibility to cancer leads to the question whether these procedures are cost effective for the executing hospitals. This study compared the clinical costs for bilateral risk-reducing mastectomy (BRRM) with and without different types of reconstruction, risk-reducing salpingo-oophorectomy (RRSO), and their combinations with corresponding reimbursements in the statutory health-care system in Germany. Patients and methods Real total costs of care for BRRM with and without reconstruction, RRSO, and their combinations were calculated as the sum of all personnel and technical costs. These costs calculated in a German University hospital were compared with the sum of all reimbursements in the German DRG-based health-care system. Results While sole RRSO, BRRM without reconstruction, and BRRM with secondary DIEP (deep inferior epigastric perforator)—reconstruction still result in a small benefit, we even found shortfalls for the hospital with all other prophylactic operations under consideration. The calculated deficits were especially high for BRRM with implant-based breast reconstruction and for combined operations when the risk reduction is achieved with a minimum of separate operations. Conclusions Risk-reducing surgery in BRCA-mutation carriers is frequently not cost-covering for the executing hospitals in the German health-care system. Thus, appropriate concepts are required to ensure a nationwide care.
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Affiliation(s)
- Michael G Schrauder
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 21-23, 91054, Erlangen, Germany. .,Department of Obstetrics and Gynecology, Hospital of Aschaffenburg-Alzenau, Aschaffenburg, Germany.
| | - Lisa Brunel-Geuder
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 21-23, 91054, Erlangen, Germany
| | - Lothar Häberle
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 21-23, 91054, Erlangen, Germany
| | - Marius Wunderle
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 21-23, 91054, Erlangen, Germany
| | - Juliane Hoyer
- Institute of Human Genetics, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Roland Csorba
- Department of Obstetrics and Gynecology, Hospital of Aschaffenburg-Alzenau, Aschaffenburg, Germany.,Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - André Reis
- Institute of Human Genetics, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rüdiger Schulz-Wendtland
- Institute of Radiology, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias W Beckmann
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 21-23, 91054, Erlangen, Germany
| | - Michael P Lux
- Department of Gynecology and Obstetrics, Erlangen University Hospital, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsstraße 21-23, 91054, Erlangen, Germany
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Müller D, Danner M, Schmutzler R, Engel C, Wassermann K, Stollenwerk B, Stock S, Rhiem K. Economic modeling of risk-adapted screen-and-treat strategies in women at high risk for breast or ovarian cancer. Eur J Health Econ 2019; 20:739-750. [PMID: 30790097 DOI: 10.1007/s10198-019-01038-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 02/12/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The 'German Consortium for Hereditary Breast and Ovarian Cancer' (GC-HBOC) offers women with a family history of breast and ovarian cancer genetic counseling. The aim of this modeling study was to evaluate the cost-effectiveness of genetic testing for BRCA 1/2 in women with a high familial risk followed by different preventive interventions (intensified surveillance, risk-reducing bilateral mastectomy, risk-reducing bilateral salpingo-oophorectomy, or both mastectomy and salpingo-oophorectomy) compared to no genetic test. METHODS A Markov model with a lifelong time horizon was developed for a cohort of 35-year-old women with a BRCA 1/2 mutation probability of ≥ 10%. The perspective of the German statutory health insurance (SHI) was adopted. The model included the health states 'well' (women with increased risk), 'breast cancer without metastases', 'breast cancer with metastases', 'ovarian cancer', 'death', and two post (non-metastatic) breast or ovarian cancer states. Outcomes were costs, quality of life years gained (QALYs) and life years gained (LYG). Important data used for the model were obtained from 4380 women enrolled in the GC-HBOC. RESULTS Compared with the no test strategy, genetic testing with subsequent surgical and non-surgical treatment options provided to women with deleterious BRCA 1 or 2 mutations resulted in additional costs of €7256 and additional QALYs of 0,43 (incremental cost-effectiveness ratio of €17,027 per QALY; cost per LYG: €22,318). The results were robust in deterministic and probabilistic sensitivity analyses. CONCLUSION The provision of genetic testing to high-risk women with a BRCA1 and two mutation probability of ≥ 10% based on the individual family cancer history appears to be a cost-effective option for the SHI.
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Affiliation(s)
- Dirk Müller
- Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Gleueler Straße 176-178, 50935, Cologne, Germany.
| | - Marion Danner
- Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Gleueler Straße 176-178, 50935, Cologne, Germany
| | - Rita Schmutzler
- Center for Hereditary Breast and Ovarian Cancer, University Hospital Cologne, Kerpener Straße 34, 50931, Cologne, Germany
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Kirsten Wassermann
- Center for Hereditary Breast and Ovarian Cancer, University Hospital Cologne, Kerpener Straße 34, 50931, Cologne, Germany
| | - Björn Stollenwerk
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Gleueler Straße 176-178, 50935, Cologne, Germany
| | - Kerstin Rhiem
- Center for Hereditary Breast and Ovarian Cancer, University Hospital Cologne, Kerpener Straße 34, 50931, Cologne, Germany
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Zoukar O, Haddad A, Daldoul A, Zaied S, Salem AB, Zouari I, Faleh R. [Genital metastases from breast cancer: study of 3 cases and literature review]. Pan Afr Med J 2018; 30:7. [PMID: 30123410 PMCID: PMC6093589 DOI: 10.11604/pamj.2018.30.7.14839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/22/2018] [Indexed: 11/24/2022] Open
Abstract
Le cancer du sein est le cancer le plus fréquent chez la femme, et son pronostic dépend en grande partie de l'existence de métastases. Le foie, le squelette et les poumons en sont les sites les plus fréquents, alors que les métastases génitales semblent plus rares et moins connues. La découverte d'une masse ovarienne chez une femme présentant un antécédent de cancer du sein pose le problème de son origine primitive ou secondaire. La fréquence rapportée dans la littérature des métastases ovariennes est d'environ 20 à 30 %. Cependant, lorsque l'on découvre une masse ovarienne chez une femme atteinte de cancer du sein, il s'agit trois fois plus souvent d'une tumeur ovarienne primitive que d'une métastase. La localisation utérine cervicale ou corporéale est encore plus rare. Leur diagnostic est souvent tardif, en raison de leur latence clinique; l'échographie, notamment par voie endovaginale et couplée au Doppler couleur, et le Frottis cervico-utérin doivent être réalisés de première intention sachant que leur rendement pour leur dépistage des masses ovariennes semble très faible. L'augmentation des marqueurs tumoraux CA 15-3 et ACE doit conduire à la recherche de métastases, mais ne fournit pas d'orientation diagnostique vers un site métastatique précis. Enfin, c'est l'examen anatomopathologique qui permettra de poser le diagnostic avec certitude. Les auteurs rapportent 3 observations de métastases génitales de cancer primitif mammaire (deux ovariennes et une cervicale utérine) soulignent l'intérêt de l'examen génital précis et régulier dans la surveillance des cancers du sein et discutent les facteurs prédictifs de leur survenue.
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Affiliation(s)
- Olfa Zoukar
- Service de Gynécologie, Centre de Maternité et de Néonatologie de Monastir (CMNM), Tunisie
| | - Anis Haddad
- Service de Gynécologie, Centre de Maternité et de Néonatologie de Monastir (CMNM), Tunisie
| | - Amira Daldoul
- Service de Carcinologie du Centre de Maternité et de Néonatologie de Monastir, Tunisie
| | - Sonia Zaied
- Service de Carcinologie du Centre de Maternité et de Néonatologie de Monastir, Tunisie
| | - Amina Ben Salem
- Service de Radiologie du Centre de Maternité et de Néonatologie de Monastir, Tunisie
| | - Ines Zouari
- Service de Gynécologie, Centre de Maternité et de Néonatologie de Monastir (CMNM), Tunisie
| | - Raja Faleh
- Service de Gynécologie, Centre de Maternité et de Néonatologie de Monastir (CMNM), Tunisie
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Moberg IO, Schou Bredal I, Schneider MR, Tønseth KA, Schlichting E. Complications, risk factors, and patients-reported outcomes after skin-sparing mastectomy followed by breast reconstruction in women with BRCA mutations. J Plast Surg Hand Surg 2018; 52:234-239. [DOI: 10.1080/2000656x.2018.1470093] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Ingvild O. Moberg
- Department for Cancer, Unit for Breast and Endocrine Surgery, Oslo University Hospital, Oslo, Norway
| | - Inger Schou Bredal
- Department for Cancer, Unit for Breast and Endocrine Surgery, Oslo University Hospital & Faculty of Medicine, Institute for Health and Society, University of Oslo, Oslo, Norway
| | - Michael R. Schneider
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Kim A. Tønseth
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ellen Schlichting
- Department for Cancer, Unit for Breast and Endocrine Surgery, Oslo University Hospital, Oslo, Norway
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Frey JD, Salibian AA, Schnabel FR, Choi M, Karp NS. Non-BRCA1/2 Breast Cancer Susceptibility Genes: A New Frontier with Clinical Consequences for Plastic Surgeons. Plast Reconstr Surg Glob Open 2017; 5:e1564. [PMID: 29263966 DOI: 10.1097/GOX.0000000000001564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/22/2017] [Indexed: 12/03/2022]
Abstract
Twenty percent of breast cancer cases may be related to a genetic mutation conferring an increased risk of malignancy. The most common and prominent breast cancer susceptibility genes are BRCA1 and BRCA2, found in nearly 40% of such cases. However, continued interest and investigation of cancer genetics has led to the identification of a myriad of different breast cancer susceptibility genes. Additional genes, each with unique significance and associated characteristics, continue to be recognized. Concurrently, advanced genetic testing, while still controversial, has become more accessible and cost-effective. As oncologic and reconstructive advances continue to be made in prophylactic breast reconstructive surgery, patients may present to plastic surgeons with an increasingly more diverse array of genetic diagnoses to discuss breast reconstruction. It is therefore imperative that plastic surgeons be familiar with these breast cancer susceptibility genes and their clinical implications. We, therefore, aim to review the most common non-BRCA1/2 breast cancer susceptibility genetic mutations in an effort to assist plastic surgeons in counseling and managing this unique patient population. Included in this review are syndromic breast cancer susceptibility genes such as TP53, PTEN, CDH1, and STK11, among others. Nonsyndromic breast cancer susceptibility genes herein reviewed include PALB2, CHEK2, and ataxia telangiectasia mutated gene. With this knowledge, plastic surgeons can play a central role in the diagnosis and comprehensive treatment, including successful breast reconstruction, of all patients carrying genetic mutations conferring increased risk for breast malignancies.
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Abstract
Risk-reducing surgery has proved to be a reasonable procedure in healthy women with a definitely elevated risk of developing cancer. Here we consider the elevated risk of breast and ovarian cancer. There is a clear indication for such surgery in healthy women with a pathogenic BRCA1/2 mutation. For these patients, a risk-reducing bilateral mastectomy leads to a verifiable reduction in mortality from breast cancer, particularly for young patients. In most cases, surgery is combined with breast reconstruction. The pros and cons of surgical treatment and the different surgical techniques have to be explained to and carefully considered with the patient. As yet, no unequivocal data for the benefits of intensifying early detection have been ascertained with respect to mortality from breast carcinoma. In index patients with a BRCA mutation, the surgical treatment should depend on the prognosis of the primary disease. A lower age at onset and a better prognosis of the primary disease make a contralateral mastectomy (CPM) more reasonable. In the case of BRCA mutation-related cancer, a reduction of mortality through CPM has been proven. A risk-reducing adnexectomy is basically recommended for BRCA mutation carriers. Healthy premenopausal women need a subsequent hormone replacement therapy. The prognosis of the patients is dominated by the ovarian carcinoma. This can be prevented by risk-reducing salpingo-oophorectomy in 95% of the cases.
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Affiliation(s)
- Christine Mau
- Interdisziplinäres Brustzentrum, Helios-Klinikum Berlin-Buch, Berlin, Germany
| | - Michael Untch
- Interdisziplinäres Brustzentrum, Helios-Klinikum Berlin-Buch, Berlin, Germany
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Kearton S, Wills K, Bunting M, Blomfield P, James PA, Burke J. Cancer risk management in Tasmanian women with BRCA1 and BRCA2 mutations. Fam Cancer 2018; 17:333-44. [PMID: 29039136 DOI: 10.1007/s10689-017-0047-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Women carrying germline mutations in BRCA1 or BRCA2 have significantly increased lifetime risks of breast and tubo-ovarian cancer. To manage the breast cancer risk women may elect to have breast screening by MRI/mammogram from age 30, to take risk-reducing medication, or to have a prophylactic bilateral mastectomy. To manage the tubo-ovarian cancer risk, the only effective strategy is to have a bilateral salpingo-oophorectomy, recommended by age 40 (BRCA1) or 'around' age 40 (BRCA2). Early studies suggested that uptake of these cancer risk-reducing strategies was low. More recent studies have revealed higher rates of uptake, however it is unclear whether uptake is genuinely improving or whether the higher uptake rates reflect changes in the populations studied. In this study we surveyed 193 BRCA1/2 mutation carriers in the state of Tasmania to determine the uptake of cancer risk-reducing strategies and what factors might influence women's decisions in relation to both gynaecological and breast surgery. We observed that uptake of risk management strategies varied depending on the strength of the recommendation in the national guidelines. Uptake rates were > 90% for strategies which are strongly recommended, such as breast screening by MRI/mammogram and bilateral salpingo-oophorectomy, and were unaffected by demographic factors such as socio-economic disadvantage and educational achievement. Uptake rates were much lower for strategies which are presented in the guidelines as options for consideration and where patient choice and shared decision making are encouraged, such as prophylactic mastectomy (29%) and chemoprevention (1%) and in the case of prophylactic mastectomy, were influenced by both socio-economic advantage and educational achievement.
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Kostev K, Jacob L, Kalder M. Risk of depression, anxiety, and adjustment disorders in women with a suspected but unconfirmed diagnosis of breast or genital organ cancer in Germany. Cancer Causes Control 2017; 28:1021-6. [DOI: 10.1007/s10552-017-0948-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/23/2017] [Indexed: 12/27/2022]
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