Evolving Trends and Influencing Factors in Mastectomy Decisions

It is known that survival is unaffected by the choice of surgical management for breast cancer (BC) patients. Despite this fact, recent literature reveals that the number of bilateral mastectomies (BMs) in the United States is increasing. In an effort to elucidate potential factors influencing this trend, we investigated socioeconomic and clinicopathologic characteristics of our patient cohort that could have affected a patient's decision between unilateral mastectomy (UM) versus BM. Five-hundred-eight patients with unilateral BC who underwent mastectomy between 2000 and 2009 were analyzed: 397-UM; 111-BM. Influence of patient's age, insurance status, residence (rural versus urban), subsequent reconstruction, marital status, smoking history, family cancer history, cancer stage and grade on the BM versus UM patient's decision were analyzed using independent sample t tests, χ2 and logistic regression analysis. BM was more likely to be chosen by younger (<50 years) patients (P < 0.001); patients with private insurance [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.4–3.5]; residence in urban settings (OR = 5.09, 95% CI = 2.5–10.4); and plans for subsequent reconstruction (OR = 2.31, 95% CI = 1.4–3.8). Marital status, smoking history, family cancer history, BC stage and grade did not significantly impact patient's choice of BM versus UM. We found that patients with unilateral BC who are younger (<50 year) have private insurance, reside in urban settings, or plan for subsequent reconstruction are more likely to undergo BM for unilateral BC. Genetic specific data were not evaluated for this patient cohort, and will be the subject of future analysis.

Society of Surgical Oncology Breast Disease Working Group Statement on Prophylactic (Risk-Reducing) Mastectomy

Over the past several years, there has been an increasing rate of bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM) surgeries. Since publication of the 2007 SSO position statement on the use of risk-reducing mastectomy, there have been significant advances in the understanding of breast cancer biology and treatment. The purpose of this manuscript is to review the current literature as a resource to facilitate a shared and informed decision-making process regarding the use of risk-reducing mastectomy.

Changing surgical trends in young patients with early stage breast cancer, 2003 to 2010: a report from the National Cancer Data Base

BACKGROUND

Young patients with breast cancer represent a unique cohort of patients who often have different treatment plans than older patients. We hypothesized that the rates of contralateral prophylactic mastectomy (CPM) were significantly higher and those of lumpectomy were significantly lower in young patients compared with older patients and that this trend persists when adjusting for patient, tumor, and facility factors.

STUDY DESIGN

We used the National Cancer Data Base (NCDB) to study 553,593 patients from all ages with American Joint Committee on Cancer (AJCC) stage 0 to II breast tumors, who underwent lumpectomy, unilateral mastectomy, or CPM from 2003 to 2010.

RESULTS

Over the entire cohort, lumpectomy rates decreased from 67.7% in 2003 to 66.4% in 2010 in contrast to women 45 years old or less, in whom the lumpectomy rates went from 61.3% in 2003 to 49.4% in 2010. Unilateral mastectomy went from 28.2% to 23.9% and CPM from 4.1% to 9.7% compared with women 45 years old or less, in whom unilateral mastectomy rates went from 29.3% to 26.4% and CPM rates from 9.3% to 26.4%. Age was the most significant factor related to increasing CPM rates: 19.7% of women between 41 and 45 years old underwent CPM vs 5.1% of women between 66 and 70 years old. There was substantial regional variation in surgical procedures for young women: lumpectomy rates were lowest in the West and CPM rates were highest in the Midwest. Multivariate logistic regression showed that women 45 years old or younger compared with women more than 45 years who underwent CPM were more likely to be Caucasian, treated at an academic/research institution, have larger tumors, higher grade, higher stage, and lobular histology.

CONCLUSIONS

The rate of CPM continues to increase, with one-quarter of younger women undergoing CPM. This trend persists across all patient, tumor, and facility characteristics.

Contralateral prophylactic mastectomy and survival: report from the National Cancer Data Base, 1998-2002

The use of contralateral prophylactic mastectomy (CPM) has been increasing despite questionable survival benefit. We examined the effect of CPM on survival using the National Cancer Data Base. We examined overall survival on 219,983 mastectomy patients diagnosed with unilateral AJCC Stage 1-III invasive breast cancer between 1998 and 2002 of which 14,994 (7 %) underwent CPM at the time of their index mastectomy. Median follow up time was 5 years. Neoadjuvant and locally advanced breast cancers were excluded. Approximately 4 % underwent CPM in 1998 compared to 9.4 % in 2002, an ~125 % increase. CPM patients were significantly younger than non-CPM patients, on managed care plans, and were treated at high volume centers. The unadjusted hazard ratio (HR) of death was 0.55 (95 % CI 0.52-0.57) for CPM compared to unilateral mastectomy. In a multivariable Cox model adjusting for age, race, stage, grade, histology, insurance, facility characteristics, use of adjuvant hormonal, chemotherapy, and radiotherapy, and year of diagnosis, the adjusted HR was 0.88 (95 % CI 0.83-0.93; p < 0.001) which translated into an absolute 5-year benefit of 2 %. There was a differential effect of CPM by stage and age: HR = 0.88 (95 % CI 0.82-0.94; p < 0.001) in women younger than 70 with stage I/II, and HR = 0.95 (95 % CI 0.88-1.04; p = 0.28) in women with stage III or older than age 69 which translated into an absolute 5-year benefit of 1.3 %. Utilization of hormonal therapy or chemotherapy had no effect on the HR. After adjusting for confounding, the overall survival benefit for CPM is minimal at best.