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Meshkani Z, Moradi N, Aboutorabi A, Farabi H, Moini N. A cost-benefit analysis of genetic screening test for breast cancer in Iran. BMC Cancer 2024; 24:279. [PMID: 38429685 PMCID: PMC10905849 DOI: 10.1186/s12885-024-12003-4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the implementation of the population- and family history (FH) -based screening for BReast CAncer (BRCA) in Iran, a country where less than 10% of breast cancer cases are attributable to a gene mutation. METHODS This was an economic evaluation study. The Benefit-Cost Ratio (BCR) for genetic screening test strategies in Iranian women older than 30 was calculated. To this end, the monetary value of the test was estimated using the willingness-to-pay (WTP) approach using the contingent valuation method (CVM) by payment card. From a healthcare perspective, direct medical and non-medical costs were considered and a decision model for the strategies was developed to simulate the costs. A one-way sensitivity analysis assessed the robustness of the analysis. The data were analyzed using Excel 2010. RESULTS 660 women were included for estimating WTP and 2,176,919 women were considered in the costing model. The cost per genetic screening test for population- and FH-based strategies was $167 and $8, respectively. The monetary value of a genetic screening test was $20 and it was $27 for women with a family history or gene mutation in breast cancer. The BCR for population-based and FH-based screening strategies was 0.12 and 3.37, respectively. Sensitivity analyses confirmed the robustness of the results. CONCLUSIONS This study recommends the implementation of a FH-based strategy instead of a population-based genetic screening strategy in Iran, although a cascade genetic screening test strategy should be evaluated in future studies.
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Affiliation(s)
- Zahra Meshkani
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
- Health Management and Economics Research Center, Iran University of Medical Sciences, 13833-19967, Tehran, Iran.
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ali Aboutorabi
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hiro Farabi
- Barts and The London Pragmatic Clinical Trial Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Nazi Moini
- Breast Cancer Research Centre, Motamed Cancer Institute, ACECR, Tehran, Iran
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2
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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3
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Zaluzec EK, Sempere LF. Systemic and Local Strategies for Primary Prevention of Breast Cancer. Cancers (Basel) 2024; 16:248. [PMID: 38254741 PMCID: PMC10814018 DOI: 10.3390/cancers16020248] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/29/2023] [Accepted: 12/31/2023] [Indexed: 01/24/2024] Open
Abstract
One in eight women will develop breast cancer in the US. For women with moderate (15-20%) to average (12.5%) risk of breast cancer, there are few options available for risk reduction. For high-risk (>20%) women, such as BRCA mutation carriers, primary prevention strategies are limited to evidence-based surgical removal of breasts and/or ovaries and anti-estrogen treatment. Despite their effectiveness in risk reduction, not many high-risk individuals opt for surgical or hormonal interventions due to severe side effects and potentially life-changing outcomes as key deterrents. Thus, better communication about the benefits of existing strategies and the development of new strategies with minimal side effects are needed to offer women adequate risk-reducing interventions. We extensively review and discuss innovative investigational strategies for primary prevention. Most of these investigational strategies are at the pre-clinical stage, but some are already being evaluated in clinical trials and others are expected to lead to first-in-human clinical trials within 5 years. Likely, these strategies would be initially tested in high-risk individuals but may be applicable to lower-risk women, if shown to decrease risk at a similar rate to existing strategies, but with minimal side effects.
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Affiliation(s)
- Erin K. Zaluzec
- Precision Health Program, Michigan State University, East Lansing, MI 48824, USA;
- Department of Pharmacology & Toxicology, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Lorenzo F. Sempere
- Precision Health Program, Michigan State University, East Lansing, MI 48824, USA;
- Department of Radiology, College of Human Medicine, Michigan State University, East Lansing, MI 48824, USA
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Møller NB, Boonen DS, Feldner ES, Hao Q, Larsen M, Lænkholm AV, Borg Å, Kvist A, Törngren T, Jensen UB, Boonen SE, Thomassen M, Terkelsen T. Validation of the BOADICEA model for predicting the likelihood of carrying pathogenic variants in eight breast and ovarian cancer susceptibility genes. Sci Rep 2023; 13:8536. [PMID: 37237042 PMCID: PMC10220031 DOI: 10.1038/s41598-023-35755-8] [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] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/23/2023] [Indexed: 05/28/2023] Open
Abstract
BOADICEA is a comprehensive risk prediction model for breast and/or ovarian cancer (BC/OC) and for carrying pathogenic variants (PVs) in cancer susceptibility genes. In addition to BRCA1 and BRCA2, BOADICEA version 6 includes PALB2, CHEK2, ATM, BARD1, RAD51C and RAD51D. To validate its predictions for these genes, we conducted a retrospective study including 2033 individuals counselled at clinical genetics departments in Denmark. All counselees underwent comprehensive genetic testing by next generation sequencing on suspicion of hereditary susceptibility to BC/OC. Likelihoods of PVs were predicted from information about diagnosis, family history and tumour pathology. Calibration was examined using the observed-to-expected ratio (O/E) and discrimination using the area under the receiver operating characteristics curve (AUC). The O/E was 1.11 (95% CI 0.97-1.26) for all genes combined. At sub-categories of predicted likelihood, the model performed well with limited misestimation at the extremes of predicted likelihood. Discrimination was acceptable with an AUC of 0.70 (95% CI 0.66-0.74), although discrimination was better for BRCA1 and BRCA2 than for the other genes in the model. This suggests that BOADICEA remains a valid decision-making aid for determining which individuals to offer comprehensive genetic testing for hereditary susceptibility to BC/OC despite suboptimal calibration for individual genes in this population.
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Affiliation(s)
- Nanna Bæk Møller
- Department of Clinical Genetics, Aarhus University Hospital, Brendstrupgårdsvej 21, 8200, Aarhus N, Denmark
| | - Desirée Sofie Boonen
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Elisabeth Simone Feldner
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Qin Hao
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Martin Larsen
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Anne-Vibeke Lænkholm
- Department of Surgical Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Åke Borg
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Anders Kvist
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Therese Törngren
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Uffe Birk Jensen
- Department of Clinical Genetics, Aarhus University Hospital, Brendstrupgårdsvej 21, 8200, Aarhus N, Denmark
| | - Susanne Eriksen Boonen
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Mads Thomassen
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Thorkild Terkelsen
- Department of Clinical Genetics, Aarhus University Hospital, Brendstrupgårdsvej 21, 8200, Aarhus N, Denmark.
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Gaba F, Blyuss O, Tan A, Munblit D, Oxley S, Khan K, Legood R, Manchanda R. Breast Cancer Risk and Breast-Cancer-Specific Mortality following Risk-Reducing Salpingo-Oophorectomy in BRCA Carriers: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15051625. [PMID: 36900415 PMCID: PMC10001253 DOI: 10.3390/cancers15051625] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 01/11/2023] [Revised: 02/20/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Risk-reducing salpingo-oophorectomy (RRSO) is the gold standard method of ovarian cancer risk reduction, but the data are conflicting regarding the impact on breast cancer (BC) outcomes. This study aimed to quantify BC risk/mortality in BRCA1/BRCA2 carriers after RRSO. METHODS We conducted a systematic review (CRD42018077613) of BRCA1/BRCA2 carriers undergoing RRSO, with the outcomes including primary BC (PBC), contralateral BC (CBC) and BC-specific mortality (BCSM) using a fixed-effects meta-analysis, with subgroup analyses stratified by mutation and menopause status. RESULTS RRSO was not associated with a significant reduction in the PBC risk (RR = 0.84, 95%CI: 0.59-1.21) or CBC risk (RR = 0.95, 95%CI: 0.65-1.39) in BRCA1 and BRCA2 carriers combined but was associated with reduced BC-specific mortality in BC-affected BRCA1 and BRCA2 carriers combined (RR = 0.26, 95%CI: 0.18-0.39). Subgroup analyses showed that RRSO was not associated with a reduction in the PBC risk (RR = 0.89, 95%CI: 0.68-1.17) or CBC risk (RR = 0.85, 95%CI: 0.59-1.24) in BRCA1 carriers nor a reduction in the CBC risk in BRCA2 carriers (RR = 0.35, 95%CI: 0.07-1.74) but was associated with a reduction in the PBC risk in BRCA2 carriers (RR = 0.63, 95%CI: 0.41-0.97) and BCSM in BC-affected BRCA1 carriers (RR = 0.46, 95%CI: 0.30-0.70). The mean NNT = 20.6 RRSOs to prevent one PBC death in BRCA2 carriers, while 5.6 and 14.2 RRSOs may prevent one BC death in BC-affected BRCA1 and BRCA2 carriers combined and BRCA1 carriers, respectively. CONCLUSIONS RRSO was not associated with PBC or CBC risk reduction in BRCA1 and BRCA2 carriers combined but was associated with improved BC survival in BC-affected BRCA1 and BRCA2 carriers combined and BRCA1 carriers and a reduced PBC risk in BRCA2 carriers.
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Affiliation(s)
- Faiza Gaba
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB24 3FX, UK
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, UK
| | - Oleg Blyuss
- Wolfson Institute of Population Health, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child’s Health, Sechenov First Moscow State Medical University (Sechenov University), 29 Shmitovskiy Proezd, 123337 Moscow, Russia
| | - Alex Tan
- Wolfson Institute of Population Health, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child’s Health, Sechenov First Moscow State Medical University (Sechenov University), 29 Shmitovskiy Proezd, 123337 Moscow, Russia
- Care for Long Term Conditions Division, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK
- Solov’ev Research and Clinical Center for Neuropsychiatry, 43 Ulitsa Donskaya, 115419 Moscow, Russia
| | - Samuel Oxley
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, UK
- Wolfson Institute of Population Health, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Khalid Khan
- Department of Preventive Medicine and Public Health, Universidad de Granada, 18071 Granada, Spain
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Ranjit Manchanda
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, UK
- Wolfson Institute of Population Health, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- MRC Clinical Trials Unit, University College London, 90 High Holborn, London WC1V 6LJ, UK
- Department of Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
- Correspondence:
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Zimovjanova M, Bielcikova Z, Miskovicova M, Vocka M, Zimovjanova A, Rybar M, Novotny J, Petruzelka L. Uptake and Effectiveness of Risk-Reducing Surgeries in Unaffected Female BRCA1 and BRCA2 Carriers: A Single Institution Experience in the Czech Republic. Cancers (Basel) 2023; 15:cancers15041072. [PMID: 36831416 PMCID: PMC9954081 DOI: 10.3390/cancers15041072] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
Unnafected female carriers of BRCA1 and BRCA2 pathogenic/likely pathogenic variants (P/LPVs) are at higher risk of breast cancer (BC) and ovarian cancer (OC). In the retrospective single-institution study in the Czech Republic, we analyzed the rate, longitudinal trends, and effectiveness of prophylactic risk-reducing mastectomy (RRM) and risk-reducing salpingo-oophorectomy (RRSO) on the incidence of BC and OC in BRCA1/2 carriers diagnosed between years (y) 2000 to 2020. The study included 496 healthy female BRCA1/2 carriers. The median follow-up was 6.0 years. RRM was performed in 156 (31.5%, mean age 39.3 y, range 22-61 y) and RRSO in 234 (47.2%, mean age 43.2 y, range 28-64 y) BRCA1/2 carriers. A statistically significant increase of RRM (from 12% to 29%) and RRSO (from 31% to 42%) was observed when comparing periods 2005-2012 and 2013-2020 (p < 0.001). BC developed in 15.9% of BRCA1/2 carriers without RRM vs. 0.6% of BRCA1/2 carriers after RRM (HR 20.18, 95% CI 2.78- 146.02; p < 0.001). OC was diagnosed in 4.3% vs. 0% of BRCA1/2 carriers without vs. after RRSO (HR not defined due to 0% occurrence in the RRSO group, p < 0.001). Study results demonstrate a significant increase in the rate of prophylactic surgeries in BRCA1/2 healthy carriers after 2013 and the effectiveness of RRM and RRSO on the incidence of BC and OC in these populations.
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Affiliation(s)
- Martina Zimovjanova
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, 128 08 Prague, Czech Republic
- Correspondence: ; Tel.: +420-224-966-764
| | - Zuzana Bielcikova
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, 128 08 Prague, Czech Republic
| | - Michaela Miskovicova
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, 128 08 Prague, Czech Republic
- Department of Oncology, Nitra Faculty Hospital, Špitálska 6, 949 01 Nitra, Slovakia
| | - Michal Vocka
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, 128 08 Prague, Czech Republic
| | - Anna Zimovjanova
- Faculty of Medicine, Masaryk University, 601 77, Kamenice 5, 625 00 Brno, Czech Republic
- International Clinical Research Center (ICRC) of St Anne’s University Hospital (FNUSA), Pekařská 664/53, 602 00 Brno, Czech Republic
| | - Marian Rybar
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University, náměstí Sítná 3105, 272 01 Kladno, Czech Republic
| | - Jan Novotny
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, 128 08 Prague, Czech Republic
- Department of Surgery, Sunderby Hospital, Sjukhusvägen 10, 954 42 Sunderbyn, Sweden
| | - Lubos Petruzelka
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, 128 08 Prague, Czech Republic
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Powell CB, Laurent C, Garcia C, Hoodfar E, Karlea A, Kobelka C, Lee J, Roh J, Kushi LH. Management of ovarian and breast cancer risk in non-BRCA HBOC pathogenic variant carriers in a large California health care system. Gynecol Oncol 2022; 167:467-475. [PMID: 36220669 DOI: 10.1016/j.ygyno.2022.10.001] [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: 08/17/2022] [Revised: 09/28/2022] [Accepted: 10/01/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE To describe breast and ovarian cancer risk reduction strategies in the clinical management of women who test positive for non-BRCA hereditary breast and ovarian cancer (HBOC) pathogenic variants compared to those who test positive for pathogenic BRCA variants or have negative germline panel testing. METHODS Examination of imaging and preventive surgeries in women undergoing HBOC genetic testing from 1/1/2015 to 12/31/2018, with follow up to 03/31/2020 in Kaiser Permanente Northern California. RESULTS A total of 13,271 tests which included HBOC genes were identified. Rate of bilateral salpingo-oophorectomy after genetic testing were similar for BRCA and the non-BRCA moderate risk ovarian pathogenic variants (PVs) (47.4% vs 54%, p = 0.25). Rates were lower for low risk or unknownrisk non-BRCA PVs (12.8%, p < 0.001, 5.3% (p < 0.001). Rates of surveillance for ovarian cancer with ultrasound and CA 125 in the first year was 63.3% and 64.7% for BRCA PV, 37.5% and 27.1%, for non-BRCA moderate risk PVs and 13.7% and 4.6%, for low-risk PVs. Bilateral mastectomy rates were 19.7% for BRCA PV, 10.1% (p = 0.028) for non-BRCA breast high risk PVs, for moderate risk PVs 7.7% (p < 0.001) and for unknown risk 0.4% (p < 0.001). MRI surveillance rates in the first year similarly were 47.4% for non-BRCA BRCA PV, 43% for breast high risk PV, 39.4% for moderate risk and 4.9% for unknown risk PV. CONCLUSION Surgical and surveillance strategies are underutilized for HBOC PV, however there is concordance of uptake of preventive strategies with specific risk associated with non-BRCA PVs.
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Affiliation(s)
- C Bethan Powell
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America; Kaiser Permanente Northern California Hereditary Cancer Program, San Francisco, United States of America.
| | - Cecile Laurent
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
| | - Christine Garcia
- Kaiser Permanente Northern California Hereditary Cancer Program, San Francisco, United States of America
| | - Elizabeth Hoodfar
- Kaiser Permanente Northern California Hereditary Cancer Program, San Francisco, United States of America; Kaiser Permanente Northern California Genetics Department
| | - Audrey Karlea
- Kaiser Permanente Northern California Hereditary Cancer Program, San Francisco, United States of America; Kaiser Permanente Northern California Genetics Department
| | - Christine Kobelka
- Kaiser Permanente Northern California Hereditary Cancer Program, San Francisco, United States of America; Kaiser Permanente Northern California Genetics Department
| | - Jaimie Lee
- Kaiser Permanente Oakland Obstetrics and Gynecology Residency Program
| | - Janise Roh
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
| | - Lawrence H Kushi
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
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Comeaux JG, Culver JO, Lee JE, Dondanville D, McArthur HL, Quinn E, Gorman N, Ricker C, Li M, Lerman C. Risk‐reducing mastectomy decisions among women with mutations in high‐ and moderate‐ penetrance breast cancer susceptibility genes. Mol Genet Genomic Med 2022; 10:e2031. [PMID: 36054727 PMCID: PMC9544212 DOI: 10.1002/mgg3.2031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/25/2022] [Indexed: 12/02/2022] Open
Abstract
Background Women harboring mutations in breast cancer susceptibility genes are at increased lifetime risk of developing breast cancer and are faced with decisions about risk management, including whether to undergo high‐risk screening or risk‐reducing mastectomy (RRM). National guidelines recommend BRCA1 or BRCA2 mutation carriers consider RRM, but that carriers of moderate penetrance mutations (e.g., ATM or CHEK2) should be managed based on family history. We aimed to investigate determinants of decision for RRM, and hypothesized that mutation status, age, family history, partner status, and breast cancer would impact RRM decision making. Methods We performed a retrospective study assessing RRM decisions for 279 women. Results Women with BRCA and moderate penetrance gene mutations, a personal history of breast cancer, or a first degree relative with a history of breast cancer were more likely to undergo RRM. Breast cancer status and age showed an interaction effect such that women with breast cancer were less likely to undergo RRM with increasing age. Conclusion Although national guidelines do not recommend RRM for moderate penetrance carriers, the rates of RRM for this population approached those for BRCA mutation carriers. Further insights are needed to better support RRM decision‐making in this population.
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Affiliation(s)
- Jacob G. Comeaux
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Julie O. Culver
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - John E. Lee
- Samuel Oschin Cancer CenterCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | - Heather L. McArthur
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Emily Quinn
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Nicholas Gorman
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Charité Ricker
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ming Li
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Caryn Lerman
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Siegel A, Bremer RC, Klein WMP, Savage SA, Loud JT, Khincha PP. Uptake and timing of bilateral and contralateral risk-reducing mastectomy in women with Li-Fraumeni syndrome. Breast Cancer Res Treat 2021. [PMID: 34652547 DOI: 10.1007/s10549-021-06410-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Women with Li-Fraumeni Syndrome (LFS) often consider risk-reducing mastectomy (RRM) due to extremely high risk of breast cancer at early ages. Data on uptake of RRM in LFS are scarce, and are inferred from experience in women with pathogenic variants (PVs) in BRCA1/2, despite differences in cancer risks. This study evaluated RRM uptake in a cohort of women with LFS. METHODS Women (n = 205) with LFS enrolled in NCI's LFS study reported lifetime cancer diagnoses and mastectomies and completed questionnaires regarding reproductive history, cancer worry and risk perceptions. A subset of women participating in an annual cancer screening study received counseling regarding RRM. RESULTS 65% (n = 71) of women diagnosed with presumed unilateral breast cancer (n = 109) underwent contralateral RRM over their lifetime. Nearly half (49%, n = 25) of the women who did not complete contralateral RRM within one year of their breast cancer diagnosis (n = 51) developed contralateral breast cancer (median interval = 6 years). Only 18.5% (n = 15) of women without breast cancer history (n = 81) underwent bilateral RRM. Median age at bilateral RRM of 39 years was sub-optimal for breast cancer risk reduction. Contralateral RRM was associated with early genetic diagnosis, participation in the screening study, and fewer prior cancers. Bilateral RRM uptake was associated with having had children, having breastfed, and high cancer worry. CONCLUSION Uptake of contralateral RRM is high in women with LFS. The frequency of contralateral breast cancer necessitates active discussion of benefits of contralateral RRM and counseling regarding bilateral RRM should be tailored to the early age at risk of breast cancer onset in LFS. There is a need for research into the survival and long-term benefits of RRM in LFS.
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Evans DG, Gandhi A, Wisely J, Clancy T, Woodward ER, Harvey J, Highton L, Murphy J, Barr L, Howell SJ, Lalloo F, Harkness EF, Howell A. Uptake of bilateral-risk-reducing-mastectomy: Prospective analysis of 7195 women at high-risk of breast cancer. Breast 2021; 60:45-52. [PMID: 34464846 DOI: 10.1016/j.breast.2021.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 07/31/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022] Open
Abstract
Background Bilateral-Risk-Reducing-Mastectomy-(BRRM) is well described in BRCA1/2 pathogenic variant carriers. However, little is known about the relative uptake, time trends or factors influencing uptake in those at increased breast cancer risk not known to be carriers. The aim of this study is to assess these factors in both groups. Methods BRRM uptake was assessed from entry to the Manchester Family History Clinic or from date of personal BRCA1/2 test. Follow up was censored at BRRM, breast cancer diagnosis, death or January 01, 2020. Cumulative incidence and cause specific and competing risk regression analyses were used to assess the significance of factors associated with BRRM. Results Of 7195 women at ≥25% lifetime breast cancer risk followed for up to 32 years, 451 (6.2%) underwent pre-symptomatic BRRM. Of those eligible in different risk groups the 20-year uptake of BRRM was 47.7%-(95%CI = 42.4–53.2%) in 479 BRCA1/2 carriers; 9.0% (95%CI = 7.26–11.24%) in 1261 women at ≥40% lifetime risk (non-BRCA), 4.8%-(95%CI = 3.98–5.73%) in 3561 women at 30–39% risk and 2.9%-(95%CI = 2.09–4.09%) in 1783 women at 25–29% lifetime risk. In cause-specific Cox regression analysis death of a sister with breast cancer<50 (OR = 2.4; 95%CI = 1.7–3.4), mother<60 (OR = 1.9; 95%CI = 1.5–2.3), having children (OR = 1.4; 95%CI = 1.1–1.8), breast biopsy (OR = 1.4; 95%CI = 1.0–1.8) were all independently associated with BRRM uptake, while being older at assessment was less likely to be associated with BRRM (>50; OR = 0.26,95%CI = 0.17–0.41). Uptake continued to rise to 20 years from initial risk assessment. Conclusion We have identified several additional factors that correlate with BRRM uptake and demonstrate continued increases over time. These factors will help to tailor counselling and support for women. BRRM continues even 20 years post original breast cancer risk assessment. Potential triggers include death of mother/sister, children and a breast biopsy. Uptake is clearly informed by lifetime risk of BC and higher in younger the women.
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11
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Park B, Kim D, Kim J, Lee BY, Yoon J, Kim SW. Attitudes toward Risk-Reducing Mastectomy and Risk-Reducing Salpingo-oophorectomy among Young, Unmarried, Healthy Women in Korea. Cancer Res Treat 2021; 54:375-382. [PMID: 34384016 PMCID: PMC9016293 DOI: 10.4143/crt.2021.449] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose This study investigated the attitudes toward risk-reducing mastectomy (RRM) and risk-reducing salpingo-oophorectomy (RRSO) as cancer prevention options for BRCA1/2 carriers in healthy, young, unmarried Korean women. Materials and Methods A nationally representative sample of 600 women, aged 20–39 years, completed a questionnaire on sociodemographic variables, preference for genetic testing, and intention to undergo risk-reducing surgeries after receiving information on the cancer risk of BRCA1/2 mutations and benefits of risk-reducing surgeries. Results A total of 54.7% and 57.7% had the intention to undergo RRM and RRSO, respectively, on the assumption that they were BRCA1/2 carriers. Older age and no intention to undergo genetic testing were associated with a reduced likelihood of undergoing RRM (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.14 to 0.61 for age 35–39 years and OR, 0.35; 95% CI, 0.20 to 0.62 for no intention for genetic testing) and RRSO (OR, 0.39; 95% CI, 0.19 to 0.79 for age 35–39 years and OR, 0.30; 95% CI, 0.17 to 0.53 for no intention for genetic testing). Women who chose to be single were likely to undergo risk-reducing surgeries (OR, 1.67; 95% CI, 1.07 to 2.60 for RRM and OR, 1.56; 95% CI, 1.00 to 2.44 for RRSO). Conclusion More than 50% of healthy, unmarried, young Korean women were inclined to undergo prophylactic surgeries if they were BRCA1/2 mutation carriers. Further studies on decision-making process for cancer prevention in individuals at high risk for cancer need to be conducted.
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Affiliation(s)
- Boyoung Park
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dongwon Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Jiyoung Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Bom Yi Lee
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Junghyun Yoon
- Department of Health Sciences, Hanyang University College of Medicine, Seoul, Korea
| | - Sung-Won Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
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12
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Padamsee TJ, Meadows R, Hils M. Layers of information: interacting constraints on breast cancer risk-management by high-risk African American women. Ethn Health 2021; 26:787-810. [PMID: 30589360 PMCID: PMC9529154 DOI: 10.1080/13557858.2018.1562053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 06/29/2018] [Accepted: 11/20/2018] [Indexed: 06/09/2023]
Abstract
Objectives: To understand how various decision-making dynamics interact to shape the risk-management choices of African American women at high-risk of breast cancer, and to explore whether African American and White women have differential access to the information and interactions that promote proactive, confident risk-management behavior.Design: This paper draws on 50 original in-depth, semi-structured interviews with African American and White women at elevated risk of breast cancer. We used inductive grounded-theory methodology to explore the processes by which women make risk-management decisions and to compare those processes between racial groups. Moving backward from women's decisions about whether or not to engage in specific risk-management behaviors, we explored the patterns that underlie behavioral decisions.Results: We find that decisions to engage in risk-management behavior rest on three accumulated layers of information. The layer most proximal to making risk-management decisions involves specific information about risk-management options; the middle layer involves general information about managing breast cancer risk; and the foundational layer involves personal perceptions of breast cancer risk and prevention. African American and White women experience distinct dynamics at each of these levels, and these differences may help explain racial differences in risk-management behavior. Compared to their White counterparts, African American women faced additional burdens at every step along the risk-management journey.Conclusion: These findings suggest that information gathering is more complex than has previously been addressed, that information access and provider access are closely related, and that African American women may be systematically disadvantaged with respect to information-generating experiences. Preventing cancer morbidity and mortality requires that all high-risk women have access to the layers of information necessary to engage in cancer screenings and preventive interventions. These results exemplify the ways that structural, social, and interpersonal inequalities combine to influence risk-management choices.
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Affiliation(s)
- Tasleem J. Padamsee
- Corresponding Author. 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, United States; ; Phone: 1-614-688-0986; Fax: 1-614-247-1846
| | - Rachel Meadows
- Suite 525 Gateway Building C, 1590 N High Street, Columbus, OH 43201, United States
| | - Megan Hils
- 282-2 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, United States
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13
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Makhnoon S, Tran G, Levin B, Mattie KD, Dreyer B, Volk RJ, Grana G, Arun BK, Peterson SK. Uptake of cancer risk management strategies among women who undergo cascade genetic testing for breast cancer susceptibility genes. Cancer 2021; 127:3605-3613. [PMID: 34157779 DOI: 10.1002/cncr.33668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/25/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uptake of cancer risk management based on inherited predispositions, which encompasses bilateral mastectomy (BLM), bilateral salpingo-oophorectomy (BSO), and intensified screening, is the primary motivation for cascade testing for hereditary breast and ovarian cancer (HBOC). However, long-term outcome data for cascade testers are lacking. METHODS Medical records were abstracted for all unaffected women with pathogenic variants in HBOC genes from 2 cancer hospitals (2013-2019) with at least 1 year of follow-up to compare the uptake of surgery and screening between cascade and noncascade testers. RESULTS Cascade testers (79.8%) were younger than noncascade testers (mean age, 37.6 vs 43.5 years; P = .002). Among women aged ≥40 years, 43% underwent BLM, and 71.6% underwent BSO, with no significant difference in uptake between cascade and noncascade testers. The mean time to BSO among cascade testers was shorter among women aged ≥40 years versus those aged <40 years (11.8 vs 31.9 months; P = .04); no such difference was observed among noncascade testers. Mammography and breast magnetic resonance imaging rates were low in the recorded 6 years for both groups after genetic counseling. CONCLUSIONS Management uptake among cascade testers is high with rates comparable to those for unaffected BRCA-positive women. A large proportion of women act on cascade test results, and this represents a novel report of utilization of cancer management strategies.
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Affiliation(s)
- Sukh Makhnoon
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace Tran
- Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brooke Levin
- William G. Rohrer Cancer Genetics Program, Division of Hematology and Medical Oncology, MD Anderson Cancer Center at Cooper University Health Care, Camden, New Jersey
| | - Kristin D Mattie
- William G. Rohrer Cancer Genetics Program, Division of Hematology and Medical Oncology, MD Anderson Cancer Center at Cooper University Health Care, Camden, New Jersey
| | | | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Generosa Grana
- William G. Rohrer Cancer Genetics Program, Division of Hematology and Medical Oncology, MD Anderson Cancer Center at Cooper University Health Care, Camden, New Jersey
| | - Banu K Arun
- Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
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14
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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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15
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Ložar T, Žgajnar J, Perhavec A, Blatnik A, Novaković S, Krajc M. Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia. Eur J Surg Oncol 2021; 47:1900-6. [PMID: 33812767 DOI: 10.1016/j.ejso.2021.03.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/22/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia. MATERIALS AND METHODS Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed. RESULTS Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%). CONCLUSION The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.
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16
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Marcinkute R, Woodward ER, Gandhi A, Howell S, Crosbie EJ, Wissely J, Harvey J, Highton L, Murphy J, Holland C, Edmondson R, Clayton R, Barr L, Harkness EF, Howell A, Lalloo F, Evans DG. Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers. J Med Genet 2021; 59:133-140. [PMID: 33568438 DOI: 10.1136/jmedgenet-2020-107356] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Women testing positive for BRCA1/2 pathogenic variants have high lifetime risks of breast cancer (BC) and ovarian cancer. The effectiveness of risk reducing surgery (RRS) has been demonstrated in numerous previous studies. We evaluated long-term uptake, timing and effectiveness of risk reducing mastectomy (RRM) and bilateral salpingo-oophorectomy (RRSO) in healthy BRCA1/2 carriers. METHODS Women were prospectively followed up from positive genetic test (GT) result to censor date. χ² testing compared categorical variables; Cox regression model estimated HRs and 95% CI for BC/ovarian cancer cases associated with RRS, and impact on all-cause mortality; Kaplan-Meier curves estimated cumulative RRS uptake. The annual cancer incidence was estimated by women-years at risk. RESULTS In total, 887 women were included in this analysis. Mean follow-up was 6.26 years (range=0.01-24.3; total=4685.4 women-years). RRS was performed in 512 women, 73 before GT. Overall RRM uptake was 57.9% and RRSO uptake was 78.6%. The median time from GT to RRM was 18.4 months, and from GT to RRSO-10.0 months. Annual BC incidence in the study population was 1.28%. Relative BC risk reduction (RRM versus non-RRM) was 94%. Risk reduction of ovarian cancer (RRSO versus non-RRSO) was 100%. CONCLUSION Over a 24-year period, we observed an increasing number of women opting for RRS. We showed that the timing of RRS remains suboptimal, especially in women undergoing RRSO. Both RRM and RRSO showed a significant effect on relevant cancer risk reduction. However, there was no statistically significant RRSO protective effect on BC.
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Affiliation(s)
- Ruta Marcinkute
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Emma Roisin Woodward
- Manchester Centre for Genomic Medicine, Central Manchester NHS Foundation Trust, Manchester, UK.,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ashu Gandhi
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Sacha Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, St Mary's Hospital, University of Manchester, Manchester, UK.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Julie Wissely
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - James Harvey
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Lindsay Highton
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - John Murphy
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Cathrine Holland
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard Edmondson
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, St Mary's Hospital, University of Manchester, Manchester, UK.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard Clayton
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Lester Barr
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK
| | - Elaine F Harkness
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,Manchester Breast Centre, The Christie Hospital, Manchester, UK
| | - Fiona Lalloo
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester NHS Foundation Trust, Manchester, UK .,Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Prevent Breast Cancer Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK.,NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Macadam SA, Slater K, Cheifetz RE, Jansen L, Chia S, Brasher PMA, Bovill ES. Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting? ACTA ACUST UNITED AC 2021; 28:702-15. [PMID: 33504079 DOI: 10.3390/curroncol28010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 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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18
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Park SY, Kim Y, Kim S. Factors associated with the decision to undergo risk-reducing salpingo-oophorectomy among women at high risk for hereditary breast and ovarian cancer: a systematic review. Korean J Women Health Nurs 2020; 26:285-299. [PMID: 36312308 PMCID: PMC9328615 DOI: 10.4069/kjwhn.2020.11.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose This systematic review aims to identify factors associated with risk-reducing salpingo-oophorectomy (RRSO), including the uptake rate and decision timing, among women at high risk for hereditary breast and ovarian cancer (HBOC). Methods We found 4,935 relevant studies using MEDLINE, Embase, CINAHL, and PsycINFO on July 6, 2020. Two authors screened the articles and extracted data. Twenty-four studies met the inclusion criteria. Quality assessment of articles was conducted using the Risk of Bias for Nonrandomized Studies tool. Results Five types of factors were identified (demographic factors, clinical factors, family history of cancer, psychological factors, and objective cancer risk). The specific significant factors were older age, having child(ren), being a BRCA1/2 carrier, mastectomy history, perceived risk for ovarian cancer, and perceived advantages of RRSO, whereas objective cancer risk was not significant. The uptake rate of RRSO was 23.4% to 87.2% (mean, 45.2%) among high-risk women for HBOC. The mean time to decide whether to undergo RRSO after BRCA testing was 4 to 34 months. Conclusion RRSO decisions are affected by demographic, clinical, and psychological factors, rather than objective cancer risk. Nonetheless, women seeking RRSO should be offered information about objective cancer risk. Even though decision-making for RRSO is a complex and multifaceted process, the psychosocial factors that may influence decisions have not been comprehensively examined, including family attitudes toward RRSO, cultural norms, social values, and health care providers’ attitudes.
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Affiliation(s)
- Sun-young Park
- Graduate School, Yonsei University, Seoul, Korea
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Youlim Kim
- Graduate School, Yonsei University, Seoul, Korea
- Mo-Im Kim Nursing Research Institute and College of Nursing, Yonsei University, Seoul, Korea
| | - Sue Kim
- Mo-Im Kim Nursing Research Institute and College of Nursing, Yonsei University, Seoul, Korea
- Corresponding author: Sue Kim College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2228-3276 E-mail:
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19
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Gustavsson E, Galvis G, Juth N. Genetic testing for breast cancer risk, from BRCA1/2 to a seven gene panel: an ethical analysis. BMC Med Ethics 2020; 21:102. [PMID: 33087101 PMCID: PMC7579789 DOI: 10.1186/s12910-020-00545-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/10/2019] [Accepted: 10/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background Genetic testing is moving from targeted investigations of monogenetic diseases to broader testing that may provide more information. For example, recent health economic studies of genetic testing for an increased risk of breast cancer suggest that it is associated with higher cost-effectiveness to screen for pathogenic variants in a seven gene panel rather than the usual two gene test for variants in BRCA1 and BRCA2. However, irrespective of the extent to which the screening of the panel is cost-effective, there may be ethical reasons to not screen for pathogenic variants in a panel, or to revise the way in which testing and disclosing of results are carried out.
Main text In this paper we discuss the ethical aspects of genetic testing for an increased risk of breast cancer with a special focus on the ethical differences between screening for pathogenic variants in BRCA1/2 and a seven gene panel. The paper identifies that the panel increases the number of secondary findings as well as the number of variants of uncertain significance as two specific issues that call for ethical reflection. Conclusions We conclude that while the problem of handling secondary findings should not be overstated with regard to the panel, the fact that the panel also generate more variants of uncertain significance, give rise to a more complex set of problems that relate to the value of health as well as the value of autonomy. Therefore, it is insufficient to claim that the seven gene panel is preferable by only referring to the higher cost effectiveness of the panel.
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Affiliation(s)
- Erik Gustavsson
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, 581 83, Linköping, Sweden. .,Centre for Applied Ethics, Department of Culture and Society, Linköping University, Linköping, Sweden.
| | - Giovanni Galvis
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, 581 83, Linköping, Sweden
| | - Niklas Juth
- LIME, Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
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20
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Galmor L, Bernstein-Molho R, Sklair-Levy M, Madoursky-Feldman D, Zippel D, Laitman Y, Friedman E. Time trends in uptake rates of risk-reducing mastectomy in Israeli asymptomatic BRCA1 and BRCA2 mutation carriers. Breast Cancer Res Treat 2020; 185:391-399. [PMID: 33000375 DOI: 10.1007/s10549-020-05949-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The rate of risk-reducing bilateral mastectomy (RRBM) among cancer-free Israeli female BRCA1/BRCA2 mutation carriers was reportedly 13% in 2010. Current RRBM rates in Israel and factors seemingly associated with opting for RRBM were reevaluated. METHODS Israeli female cancer-free BRCA1/BRCA2 mutation carriers, who were followed at the high-risk clinic at Sheba Medical Center between January 2011 and April 2020 were eligible. Univariate Cox regression and log-rank test were used to study the crude association between potential predictors and performance of RRBM. RESULTS Overall, 427 cancer-free BRCA1 (n = 218) or BRCA2 (n = 209) mutation carriers were included. Median age at genotyping was 33.6 years (interquartile range 26.8-41.8 years), median follow-up 4.4 years (range 0.1-7.6 years). Overall, 41/427 (9.6%) participants underwent RRBM, all of them within 5 years of genotyping. Being married (HR-2.57, p = 0.017) and having a first degree relative with breast cancer (BC) (HR-2.19, p = 0.017) were positively associated with RRBM, whereas any previous benign breast biopsy was negatively associated (HR-0.48, p = 0.029) with performing RRBM. CONCLUSIONS RRBM is still infrequently elected by Israeli BRCA1/BRCA2 mutation carriers, with married women with one relative with BC who have not undergone previous breast biopsy more likely to opt for RRBM.
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Affiliation(s)
- Lee Galmor
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rinat Bernstein-Molho
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Breast Cancer Unit, Oncology Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Miri Sklair-Levy
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Meirav High-Risk Clinic-Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Dov Zippel
- The Meirav High-Risk Clinic-Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Yael Laitman
- Oncogenetics Unit, Institute of Genetics, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Eitan Friedman
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- The Meirav High-Risk Clinic-Chaim Sheba Medical Center, Tel-Hashomer, Israel.
- Oncogenetics Unit, Institute of Genetics, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel.
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Gaba F, Blyuss O, Chandrasekaran D, Osman M, Goyal S, Gan C, Izatt L, Tripathi V, Esteban I, McNicol L, Ragupathy K, Crawford R, Evans DG, Legood R, Menon U, Manchanda R. Attitudes towards risk-reducing early salpingectomy with delayed oophorectomy for ovarian cancer prevention: a cohort study. BJOG 2020; 128:714-726. [PMID: 32803845 DOI: 10.1111/1471-0528.16424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) acceptability and effect of surgical prevention on menopausal sequelae/satisfaction/regret in women at increased ovarian cancer (OC) risk. DESIGN Multicentre, cohort, questionnaire study (IRSCTN:12310993). SETTING United Kingdom (UK). POPULATION UK women without OC ≥18 years, at increased OC risk, with/without previous RRSO, ascertained through specialist familial cancer/genetic clinics and BRCA support groups. METHODS Participants completed a 39-item questionnaire. Baseline characteristics were described using descriptive statistics. Logistic/linear regression models analysed the impact of variables on RRESDO acceptability and health outcomes. MAIN OUTCOMES RRESDO acceptability, menopausal sequelae, satisfaction/regret. RESULTS In all, 346 of 683 participants underwent risk-reducing salpingo-oophorectomy (RRSO). Of premenopausal women who had not undergone RRSO, 69.1% (181/262) found it acceptable to participate in a research study offering RRESDO. Premenopausal women concerned about sexual dysfunction were more likely to find RRESDO acceptable (odds ratio [OR] = 2.9, 95% CI 1.2-7.7, P = 0.025). Women experiencing sexual dysfunction after premenopausal RRSO were more likely to find RRESDO acceptable in retrospect (OR = 5.3, 95% CI 1.2-27.5, P < 0.031). In all, 88.8% (143/161) premenopausal and 95.2% (80/84) postmenopausal women who underwent RRSO, respectively, were satisfied with their decision, whereas 9.4% (15/160) premenopausal and 1.2% (1/81) postmenopausal women who underwent RRSO regretted their decision. HRT uptake in premenopausal individuals without breast cancer (BC) was 74.1% (80/108). HRT use did not significantly affect satisfaction/regret levels but did reduce symptoms of vaginal dryness (OR = 0.4, 95% CI 0.2-0.9, P = 0.025). CONCLUSION Data show high RRESDO acceptability, particularly in women concerned about sexual dysfunction. Although RRSO satisfaction remains high, regret rates are much higher for premenopausal women than for postmenopausal women. HRT use following premenopausal RRSO does not increase satisfaction but does reduce vaginal dryness. TWEETABLE ABSTRACT RRESDO has high acceptability among premenopausal women at increased ovarian cancer risk, particularly those concerned about sexual dysfunction.
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Affiliation(s)
- F Gaba
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - O Blyuss
- School of Physics, Astronomy and Mathematics, University of Hertfordshire, Hatfield, UK.,Department of Paediatrics and Paediatric Infectious Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Applied Mathematics, Lobachevsky State University of Nizhny Novgorod, Nizhny Novgorod, Russia
| | - D Chandrasekaran
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - M Osman
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - S Goyal
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - C Gan
- Department of Gynaecological Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - L Izatt
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - V Tripathi
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - I Esteban
- Ninewells Hospital, NHS Tayside, Dundee, UK
| | - L McNicol
- Ninewells Hospital, NHS Tayside, Dundee, UK
| | | | - R Crawford
- Department of Gynaecological Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D G Evans
- Manchester Centre for Genomic Medicine, MAHSC, Division of Evolution and Genomic Sciences, University of Manchester, Manchester, UK
| | - R Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - U Menon
- MRC Clinical Trials Unit, University College London, London, UK
| | - R Manchanda
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,MRC Clinical Trials Unit, University College London, London, UK
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22
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Gaba F, Manchanda R. Systematic review of acceptability, cardiovascular, neurological, bone health and HRT outcomes following risk reducing surgery in BRCA carriers. Best Pract Res Clin Obstet Gynaecol 2020; 65:46-65. [DOI: 10.1016/j.bpobgyn.2020.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 02/08/2023]
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Halverson CME, Connors LM, Wessinger BC, Clayton EW, Wiesner GL. Patient perspectives on variant reclassification after cancer susceptibility testing. Mol Genet Genomic Med 2020; 8:e1275. [PMID: 32329193 PMCID: PMC7336756 DOI: 10.1002/mgg3.1275] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 11/27/2019] [Revised: 01/17/2020] [Accepted: 04/02/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little is known about the impact of reclassification on patients' perception of medical uncertainty or trust in genetics-based clinical care. METHODS Semistructured telephone interviews were conducted with 20 patients who had received a reclassified genetic test result related to hereditary cancer. All participants had undergone genetic counseling and testing for cancer susceptibility at Vanderbilt-Ingram Cancer Center Hereditary Cancer Clinic within the last six years. RESULTS Most of the participants did not express distress related to the variant reclassification and only a minority expressed a decrease in trust in medical genetics. However, recall of the new interpretation was limited, even though all participants were recontacted by letter, phone, or clinic visit. CONCLUSION Reclassification of genetic tests is an important issue in modern healthcare because changes in interpretation have the potential to alter previously recommended management. Participants in this study did not express strong feelings of mistrust or doubt about their genetic evaluation. However, there was a low level of comprehension and information retention related to the updated report. Future research can build on this study to improve communication with patients about their reclassified results.
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Affiliation(s)
- Colin M E Halverson
- Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA
| | | | | | - Ellen W Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,School of Law, Vanderbilt University, Nashville, TN, USA
| | - Georgia L Wiesner
- Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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24
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25
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Evans O, Gaba F, Manchanda R. Population-based genetic testing for Women's cancer prevention. Best Pract Res Clin Obstet Gynaecol 2020; 65:139-153. [PMID: 32245629 DOI: 10.1016/j.bpobgyn.2020.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 01/21/2020] [Accepted: 02/26/2020] [Indexed: 12/15/2022]
Abstract
Germline mutations in cancer-susceptibility-genes (CSG) can dramatically increase womens' lifetime risk of ovarian, endometrial, breast and bowel cancers. Identification of unaffected carriers is important to enable proactive engagement with highly effective screening and preventive options to minimise cancer risk. Currently, a family-history model is used to identify individuals with CSGs. Complex regional referral guidelines specify the family-history criteria required before an individual is eligible for genetic-testing. This model is ineffective, resource intense, misses >50% CSG carriers, is associated with underutilisation of genetic-testing services and delays detection of mutation carriers. Although awareness and detection of CSG-carriers has improved, over 97% carriers remain unidentified. This reflects significant missed opportunities for precision-prevention. Population-based genetic-testing (PBGT) represents a novel healthcare strategy with the potential to dramatically improve detection of unaffected CSG-carriers along with enabling population risk-stratification for cancer precision-prevention. Several research studies have assessed the impact, feasibility, acceptability, long-term psychological outcomes and cost-effectiveness of population-based BRCA-testing in the Ashkenazi-Jewish population. Initial data on PBGT in the general-population is beginning to emerge and large implementation studies investigating PBGT in the general-population are needed. This review will summarise the current research into the clinical, psycho-social, health-economic, societal and ethical consequences of a PBGT model for women's cancer precision-prevention.
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Affiliation(s)
- Olivia Evans
- Wolfson Institute of Preventive Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK; Department of Gynaecological Oncology, St Bartholomew's Hospital, EC1A 7BE, London, UK
| | - Faiza Gaba
- Wolfson Institute of Preventive Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK; Department of Gynaecological Oncology, St Bartholomew's Hospital, EC1A 7BE, London, UK
| | - Ranjit Manchanda
- Wolfson Institute of Preventive Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK; Department of Gynaecological Oncology, St Bartholomew's Hospital, EC1A 7BE, London, UK.
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26
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Bahsi T, Erdem HB. Spectrum of BRCA1/BRCA2 variants in 1419 Turkish breast and ovarian cancer patients: a single center study. ACTA ACUST UNITED AC 2020. [DOI: 10.1515/tjb-2019-0424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract
Objectives
Hereditary breast and ovarian cancer syndrome is chacterized with multiple cases of breast cancer and/or ovarian cancer on the same side of the family. BRCA1/BRCA2 genes are associated with 20–25% of all patients. For developing national health policies for genetic testing, it is important to determine the range of pathogenic mutations in susceptibility genes and to identify recurrent founder mutations.
Materials and methods
All the patients were provided BRCA testing criteria according to National Comprehensive Cancer Network. QIAseq multiplex amplicon panel, BRCA MASTR™ Dx and Ion AmpliSeq Panel were used for BRCA1/BRCA2 coding regions. SALSA® MLPA® was performed for negative patients.
Results
Of 1419 patients, 134 (9.4%) were found to carry a pathogenic and 5 (0.3%) were found to carry a likely pathogenic mutation. Of those, 58 patients were found to carry a mutation in BRCA1 and 64 in BRCA2. Variant of uncertain significance was detected in 91 patients (6.4%).
Conclusion
The spectrum of BRCA1/2 mutations in Turkish population has been shown in the largest patient group to date. The thesis that founder mutations show diversity in different populations has been confirmed in our study, and the mutations that are common in Turkish population have been presented in this study.
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Klapdor R, Weiß C, Kuehnle E, Kohls F, von Ehr J, Philippeit A, Hille-Betz U. Quality of Life after Bilateral and Contralateral Prophylactic Mastectomy with Implant Reconstruction. Breast Care (Basel) 2020; 15:519-526. [PMID: 33223996 DOI: 10.1159/000505449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 09/16/2019] [Accepted: 12/16/2019] [Indexed: 01/23/2023] Open
Abstract
Background Prophylactic mastectomy is an effective approach to breast cancer risk reduction in patients at high risk. Further studies using standardized measures for quality of life are needed to better understand the effect of prophylactic mastectomy on individual patients and, thereby, allow for better patient counseling and selection. Methods In this prospective study patients undergoing bilateral mastectomy were asked to complete the BREAST-Q questionnaire before and 1 year after surgery. All patients underwent bilateral mastectomy with implant-based breast reconstruction. Patient- and surgery-related information was collected in a database. Results In total, 48 patients underwent bilateral skin-sparing mastectomy. Of these, 29 (60.4%) suffered from breast cancer. A 2-stage reconstruction with intermediate expander implantation was conducted in 19 (39.6%) patients. All patients completed the BREAST-Q questionnaire. The domain "psychosocial well-being" was significantly improved from a mean score of 74.98 preoperatively to a postoperative score of 81.56 (p = 0.021). In contrast, the domain "physical well-being" dropped -8.38 points on average to a postoperative score of 74.96 (p < 0.001). Interestingly, patients with the lowest preoperative score in the domain "satisfaction with breast" showed the greatest increase after surgery (50.31 vs. 67.25, p < 0.001). On the contrary, patients with the highest preoperative values experienced the strongest decrease in satisfaction (91.60 vs. 75.27, p = 0.012). Conclusion Implant-based prophylactic mastectomy leads to good quality-of-life results in patients at high risk for breast cancer. Especially, patients with a low preoperative satisfaction with their breasts have a significantly higher chance of experiencing substantial improvements in their quality of life.
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Affiliation(s)
- Rüdiger Klapdor
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Christina Weiß
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Elna Kuehnle
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Fabian Kohls
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Julia von Ehr
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Anja Philippeit
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Ursula Hille-Betz
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
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Terkelsen T, Rønning H, Skytte AB. Impact of genetic counseling on the uptake of contralateral prophylactic mastectomy among younger women with breast cancer. Acta Oncol 2020; 59:60-65. [PMID: 31379231 DOI: 10.1080/0284186x.2019.1648860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Preoperative genetic testing affects the surgical decision-making among women with breast cancer. To avoid breast-conserving surgery and to offer the possibility of mastectomy with immediate reconstruction in high-risk patients, genetic testing for pathogenic variants in BRCA1 or BRCA2 and a pedigree-based familial breast cancer risk assessment was offered to younger women with breast cancer in Denmark. We evaluated the impact of the risk stratification through genetic counseling on the uptake of contralateral prophylactic mastectomy (CPM).Material and methods: The prospective cohort study included all women with unilateral breast cancer before the age of 45 who participated in a genetic counseling program during their primary diagnostics in the Central Denmark Region (2013-2018). Each patient was followed from the time of the genetic test result to the end of follow-up to estimate the long-term uptake of CPM as a competing risk-adjusted cumulative incidence. We compared the uptake of CPM between the various genetic risk categories, ages of onset, and family histories in a multivariable Cox proportional hazards regression model, reporting hazard ratios (HR) with two-sided 95% confidence intervals (CIs).Results: 156 females, aged 21-44, learned their genetic test result within a median of 92 days [interquartile range (IQR): 75-114]. The maximal follow-up was 3.8 years (median 1.8; IQR: 0.49-2.5), after which 33% (95% CI: 24-42%) of the patients had undergone CPM. The uptake of CPM was inversely associated with the age of onset (HR 0.92; 95% CI: 0.86-0.98) and significantly higher among BRCA carriers (HR 2.9; 95% CI: 1.3-6.8) and patients from the high risk of breast cancer families (HR 5.6; 95% CI: 1.9-16) compared to the lower genetic risk categories.Conclusion: The risk stratification obtained through genetic counseling had a considerable impact on the surgical decision-making among younger women with breast cancer at long-term follow-up.
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Affiliation(s)
- Thorkild Terkelsen
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - Hanne Rønning
- Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Bine Skytte
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Hickey M, Rio I, Trainer A, Marino JL, Wrede CD, Peate M. Exploring factors that impact uptake of risk-reducing bilateral salpingo-oophorectomy (RRBSO) in high-risk women. ACTA ACUST UNITED AC 2020; 27:26-32. [DOI: 10.1097/gme.0000000000001422] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Isaksson K, Arver B, Bottai M, Pettersson A, Wickman M, Sandelin K. Bilateral Risk-Reducing Mastectomies with Implant-Based Reconstructions Followed Long Term: A Consecutive Series of 185 Patients. World J Surg 2019; 43:2262-2270. [PMID: 31119358 DOI: 10.1007/s00268-019-05037-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Bilateral risk-reducing mastectomy (BRRM) is the most effective method to prevent breast cancer in genetically predisposed women and is often performed concomitantly with breast reconstruction. The reconstruction time varies and corrective surgeries are common. METHODS This study evaluated 185 consecutive cases of BRRM and immediate breast reconstruction with implants with regard to surgical outcome and resource consumption. With an 18-year observation period, it was possible to compare permanent expander implants (PEIs) with permanent fixed volume implants (PIs). RESULTS A minimum follow-up of 2 years for all participants but one was achieved. Seventy-five percent (n = 138) of the women received PEI and 25% (n = 47) PI. In a multivariate analysis including age, BMI (<25, ≥25), smoking (yes, no), implant type (PEI, PI), incision technique, operation time and specimen weight <350 g, ≥350 g), only BMI ≥25 was associated with an increased risk of an early complication (OR 7.1, 95% CI 2.44-20.4). As expected, there was a significant difference in median reconstruction time between PEI and PI (12.4 vs. 1.0 months, p < 0.001). The cumulative reoperation-free 2-year survival was significantly higher in the PI than in the PEI group (81% vs. 26%, p < 0.001). CONCLUSION Implant-based reconstruction remains a valid option after BRRM in high-risk women. Whenever possible (low BMI and small breast volume without severe ptosis), permanent fixed volume implants can be safely recommended and are resource saving in comparison with permanent expander implants.
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Affiliation(s)
- Karin Isaksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Brita Arver
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Pettersson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Marie Wickman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Sophiahemmet University, Stockholm, Sweden
| | - Kerstin Sandelin
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Bernstein-Molho R, Kaufman B, Ben David MA, Sklair-Levy M, Feldman DM, Zippel D, Laitman Y, Friedman E. Breast cancer surveillance for BRCA1/2 mutation carriers - is "early detection" early enough? Breast 2020; 49:81-6. [PMID: 31760168 DOI: 10.1016/j.breast.2019.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 11/18/2022] Open
Abstract
Background Annual MRI screening is associated with a significant reduction in advanced-stage breast cancer diagnosis in BRCA1/2 mutation carriers. The impact that early detection has on subsequent oncological treatment is less frequently reported. In this study we compared disease stage and therapeutic approaches in BRCA1/2 mutation carriers who developed breast cancer while adhering to the recommended surveillance scheme (“known carriers”), with women who became aware of their BRCA mutation status after breast cancer diagnosis (“latent carriers"). Methods Data on tumor characteristics, disease stage, and therapeutic decisions were collected on BRCA1/2 mutation carriers treated for breast cancer at the Chaim Sheba Medical Center. Results Data were available for 298 BRCA1/2 carriers. Median follow-up was 77.4 months (range, 3.5–520). Age at diagnosis was not statistically different between known carriers (n = 96; median age at diagnosis 44.7 years) and latent carriers (n = 202; 43.7 years); p = 0.8284. Of known carriers, 19.8% were diagnosed with carcinoma in situ vs. 5% of latent carriers (p = 0.0012). Stage T1N0 disease was diagnosed in 54/96 (56.3%) of known carriers vs. 59/202 (29.2%) of latent carriers (p < 0.00001). Neoadjuvant or adjuvant chemotherapy was administered to 46/96 (47.9%) of known carriers compared with 162/202 (80.2%) of latent carriers (p < 0.00001). Conclusions While early stage breast cancer was diagnosed frequently among known BRCA1/2 carriers under tight surveillance, almost half of these women were treated with chemotherapy. Healthy BRCA1/2 mutation carriers should be informed about these rates while discussing risk-reducing surgical options. Annual MRI screening is recommended to healthy BRCA1/2 mutation carriers. Intensive surveillance enables breast cancer diagnosis at early stages. In this study ∼50% of early stage diagnosed patients received chemotherapy. This rate should be discussed with BRCA carriers considering risk-reducing options.
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Maritschnegg E, Heitz F, Pecha N, Bouda J, Trillsch F, Grimm C, Vanderstichele A, Agreiter C, Harter P, Obermayr E, Vergote I, Zeillinger R, Speiser P. Uterine and Tubal Lavage for Earlier Cancer Detection Using an Innovative Catheter: A Feasibility and Safety Study. Int J Gynecol Cancer 2018; 28:1692-8. [PMID: 30376484 DOI: 10.1097/IGC.0000000000001361] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Poor survival of high-grade serous pelvic cancer is caused by a lack of effective screening measures. The detection of exfoliated cells from high-grade serous pelvic cancer, or precursor lesions, is a promising concept for earlier diagnosis. However, collecting those cells in the most efficient way while fulfilling all requirements for a screening approach is a challenge. We introduce a new catheter for uterine and tubal lavage (UtL) and the clinical evaluation of its performance. METHODS/MATERIALS In study I, the clinical feasibility of the UtL using the new catheter was examined in 93 patients admitted for gynecologic surgery under general anesthesia. In study II, the safety of the UtL procedure was assessed. The pain during and after the UtL performed under local anesthesia was rated on a visual analog scale by 22 healthy women. RESULTS In study I, the UtL was carried out successfully in 92 (98.9%) of 93 cases by 16 different gynecologists. It was rated as easy to perform in 84.8% of patients but as rather difficult in cancer patients (odds ratio, 5.559; 95% confidence interval, 1.434-21.546; P = 0.007). For benign conditions, dilatation before UtL was associated with menopause status (odds ratio, 4.929; 95% confidence interval, 1.439-16.884; P = 0.016). In study II, the pain during UtL was rated with a median visual analog scale score of 1.6. During a period of 4 weeks after UtL, none of the participants had to use medication or developed symptoms requiring medical attention. The UtL took 6.5 minutes on average. The amount of extracted DNA was above the lower limit for a sensitive, deep-sequencing mutation analysis in all cases. CONCLUSIONS Our studies demonstrate that the UtL, using the new catheter, is a safe, reliable, and well-tolerated procedure, which does not require elaborate training. Therefore, UtL fulfils all prerequisites to be used in a potential screening setting.
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Modaffari P, Ponzone R, Ferrari A, Cipullo I, Liberale V, D'Alonzo M, Maggiorotto F, Biglia N. Concerns and Expectations of Risk-Reducing Surgery in Women with Hereditary Breast and Ovarian Cancer Syndrome. J Clin Med 2019; 8:E313. [PMID: 30841601 DOI: 10.3390/jcm8030313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/21/2019] [Accepted: 02/28/2019] [Indexed: 11/16/2022] Open
Abstract
Hereditary Breast and Ovarian Cancer syndrome (HBOC) carriers face complex decisions, which might affect their fertility and body image. Using an anonymous 40-items questionnaire we evaluated the expectations and concerns about Risk-Reducing Surgery (RRS) in 204 carriers. Participants are well-informed about the options to manage cancer risk, and women with previous cancer are more concerned with screening failure. Satisfaction with RR Mastectomy is high, even if many carriers are unsatisfied with reconstructed breast feel and nipple-areola complex tactile sensation and those with previous breast cancer report a change in their sexual habits. The decrease of libido and vaginal dryness are the most complained symptoms after RR Salpingo-Oophorectomy. Nevertheless, most carriers would choose RRS again, due to cancer risk or screening-related stress reduction. Women who deferred RRS are more afraid of menopausal symptoms and cancer risk than those who had undergone or declined surgery. Women who declined RRS feel well-informed and trust screening procedures. In conclusion, HBOC carriers consider themselves well-informed and able to choose the best option for their condition, would choose RRS again because of cancer risk and screening-related stress reduction, and those who delay RRS face a higher preoperative level of concern and need support.
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Glassey R, O'Connor M, Ives A, Saunders C, Hardcastle SJ. Influences on Satisfaction with Reconstructed Breasts and Intimacy in Younger Women Following Bilateral Prophylactic Mastectomy: a Qualitative Analysis. Int J Behav Med 2019; 25:390-398. [PMID: 29713993 DOI: 10.1007/s12529-018-9722-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 12/13/2022]
Abstract
PURPOSE The aim of this study was to explore the influences on satisfaction with reconstructed breasts and intimacy following bilateral prophylactic mastectomy (BPM) in younger women (< 35) with a strong family history of breast cancer. METHODS Twenty-six women who had undergone BPM between 1 and6 years ago were recruited from New Zealand and Australia through a genetics clinic, registry, research cohort, and online (Mage = 31). Twenty-three were BRCA mutation carriers. Qualitative interviews guided by interpretative phenomenological analysis were conducted. RESULTS Four themes were identified: satisfaction with breasts before surgery, outcome expectations, type of mastectomy, and open communication. Women who liked their breasts pre-BPM appeared less satisfied with their reconstructed breasts post-surgery, and women who disliked their breasts before BPM were more satisfied with their reconstructed breasts. Women with unrealistic expectations concerning the look and feel of reconstructed breasts were often unhappy with their reconstructed breasts and felt they did not meet their expectations. Unrealistic photos of breast reconstruction and satisfactory communication of realistic outcome expectations by surgeons or psychologists also appeared to influence satisfaction. Communication with partners prior to BPM appeared to improve satisfaction with intimacy post-BPM. CONCLUSIONS The findings suggest that satisfaction with reconstructed breasts for younger women post-BPM appeared to be influenced by realistic outcome expectations and communication with others concerning reconstructed breast appearance and intimacy post-BPM. Implications for practice include discussion of realistic reconstructed breast appearance, referral to a psychologist to discuss sensitive issues, and accurate communication of surgical risks and consequences.
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Affiliation(s)
- Rachael Glassey
- Medical School, The University of Western Australia, Perth, Australia.
| | - Moira O'Connor
- School of Psychology, Curtin University, Perth, Australia
| | - Angela Ives
- Medical School, The University of Western Australia, Perth, Australia
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Henry DA, Lee MC, Almanza D, Ahmed KA, Sun W, Boulware DC, Laronga C. 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 2019; 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] [What about the content of this article? (0)] [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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Hackett J, Thorneloe R, Side L, Wolf M, Horne R, Cuzick J, Smith SG. Uptake of breast cancer preventive therapy in the UK: results from a multicentre prospective survey and qualitative interviews. Breast Cancer Res Treat 2018; 170:633-640. [PMID: 29687178 PMCID: PMC6022517 DOI: 10.1007/s10549-018-4775-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 03/30/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Uptake of preventive therapy for women at increased breast cancer risk in England is unknown following the introduction of UK clinical guidelines in 2013. Preventive therapy could create socioeconomic inequalities in cancer incidence if it is more readily accepted by particular socio-demographic groups. In this multicentre study, we investigated uptake of tamoxifen and evaluated socio-demographic and clinical factors associated with initiation. We explored women's experiences of treatment decision-making using qualitative interview data. METHODS Between September 2015 and December 2016, women (n = 732) attending an appointment at one of 20 centres in England to discuss breast cancer risk were approached to complete a survey containing socio-demographic details and nulliparity. Of the baseline survey respondents (n = 408/732, 55.7% response rate), self-reported uptake of tamoxifen at 3-month follow-up was reported in 258 (63.2%). Sixteen women participated in semi-structured interviews. RESULTS One in seven (38/258 = 14.7%) women initiated tamoxifen. Women who had children were more likely to report use of tamoxifen than those without children (OR = 5.26; 95%CI: 1.13-24.49, p = 0.035). Interview data suggested that women weigh up risks and benefits of tamoxifen within the context of familial commitments, with exposure to significant other's beliefs and experiences of cancer and medication a basis for their decision. CONCLUSIONS Uptake of tamoxifen is low in clinical practice. There were no socio-demographic differences in uptake, suggesting that the introduction of breast cancer preventive therapy is unlikely to create socioeconomic inequalities in cancer incidence. Women's decision-making was influenced by familial priorities, particularly having children.
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Affiliation(s)
- Julia Hackett
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Rachael Thorneloe
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, UK
- UCL Institute for Women's Health, London, UK
| | - Michael Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - Rob Horne
- Centre for Behavioural Medicine, School of Pharmacy, University College London, London, UK
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Samuel G Smith
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK.
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK.
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Abstract
Nipple-sparing mastectomy is a valuable addition to the options available for women at high risk of developing breast cancer. In this review, we summarize current knowledge about the high-risk genes, BRCA1, BRCA2 and TP53 and the associated guidelines with regard to risk-reducing surgery. We consider other genetic risks and high-risk lesions. We discuss the literature on bilateral mastectomy for breast cancer risk-reduction, and the results of nipple-sparing mastectomy in particular. Finally, we report on patient satisfaction with these procedures and the impact that nipple-sparing mastectomy may have on women at high-risk of breast cancer.
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Affiliation(s)
- Rebecca S Lewis
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust and the Institute for Cancer Research, Sutton, UK
| | - Angela George
- Department of Cancer Genetics, Institute for Cancer Research and the Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Jennifer E Rusby
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust and the Institute for Cancer Research, Sutton, UK
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Elsayegh N, Webster RD, Gutierrez Barrera AM, Lin H, Kuerer HM, Litton JK, Bedrosian I, Arun BK. Contralateral prophylactic mastectomy rate and predictive factors among patients with breast cancer who underwent multigene panel testing for hereditary cancer. Cancer Med 2018; 7:2718-2726. [PMID: 29733510 PMCID: PMC6010764 DOI: 10.1002/cam4.1519] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 01/18/2018] [Revised: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
Although multigene panel testing is increasingly common in patients with cancer, the relationship between its use among breast cancer patients with non-BRCA mutations or variants of uncertain significance (VUS) and disease management decisions has not been well described. This study evaluated the rate and predictive factors of CPM patients who underwent multigene panel testing. Three hundred and fourteen patients with breast cancer who underwent multigene panel testing between 2014 and 2017 were included in the analysis. Of the 314 patients, 70 elected CPM. Election of CPM by gene status was as follows: BRCA carriers (42.3%), non-BRCA carriers (30.1%), and VUS (10.6%). CPM election rates did not differ between non-BRCA carriers and BRCA carriers (P = 0.6205). Among non-BRCA carriers, negative hormone receptor status was associated with CPM (P = 0.0115). For those with a VUS, hormone receptor status was not associated with CPM (P = 0.1879). Although the rate of CPM between BRCA carriers and non-BRCA carriers was not significantly different, the predictors of CPM were different in each group. Our analyses shed the light on the increasing use of CPM among patients who are non-BRCA carriers as well those with a VUS. Our study elucidates the differing predictive factors of CPM election among BRCA carriers, non-BRCA carries, and those with a VUS. Our findings reveal the need for providers to be cognizant that non-BRCA genes and VUS drive women to elect CPM despite the lack of data for contralateral breast cancer risk associated with these genes.
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Affiliation(s)
- Nisreen Elsayegh
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachel D Webster
- Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Henry M Kuerer
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer K Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabelle Bedrosian
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Banu K Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Glassey R, O'Connor M, Ives A, Saunders C, Hardcastle SJ. Influences on decision-making for young women undergoing bilateral prophylactic mastectomy. Patient Educ Couns 2018; 101:318-323. [PMID: 28870441 DOI: 10.1016/j.pec.2017.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 04/29/2017] [Revised: 07/26/2017] [Accepted: 08/10/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The objective of this study was to explore the influences on decision-making of younger women (<35) undergoing or considering bilateral prophylactic mastectomy (BPM). METHODS Qualitative interviews guided by interpretative phenomenological analysis (IPA) were conducted with forty-six women who had a strong family history of breast cancer (BC) who had either undergone (n=26) or were considering (n=20) BPM. Participants were recruited from Australia and New Zealand (NZ) via hospitals, a genetics clinic, a research cohort, a registry and online. RESULTS Four themes underpinning the influences on decision-making were identified: fear and anxiety, children, personal experiences with BC, health professional's influence. CONCLUSIONS The decision to undergo BPM for younger women (<35) was multifaceted, however, it appeared that fear and anxiety were the main influence. Younger women appear more anxious than previous research with older women. There appears to be few differences between those with confirmed BRCA1/2 mutations and those with no known mutation and this is clinically significant. PRACTICE IMPLICATIONS These findings have important practice implications, particularly improving communication of risk statistics, especially to those with no known mutation. Health professionals need to take into account the way younger women perceive information given to them when discussing risk.
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Affiliation(s)
- Rachael Glassey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.
| | - Moira O'Connor
- WA Centre for Cancer & Palliative Care, School of Psychology, Curtin University, Perth, Australia
| | - Angela Ives
- CaPCREU, Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Christobel Saunders
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Sarah J Hardcastle
- Health Psychology and Behavioural Medicine Research Group, School of Psychology, Curtin University, Perth, Australia
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Petelin L, Trainer AH, Mitchell G, Liew D, James PA. Cost-effectiveness and comparative effectiveness of cancer risk management strategies in BRCA1/2 mutation carriers: a systematic review. Genet Med 2018; 20:1145-1156. [PMID: 29323669 DOI: 10.1038/gim.2017.255] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/05/2017] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To review the evidence for the effectiveness and cost-effectiveness of cancer risk management interventions for BRCA carriers. METHODS Comparative effectiveness and cost-effectiveness analyses were identified by searching scientific and health economic databases. Eligible studies modeled the impact of a cancer risk management intervention in BRCA carriers on life expectancy (LE), cancer incidence, or quality-adjusted life years (QALYs), with or without costs. RESULTS Twenty-six economic evaluations and eight comparative effectiveness analyses were included. Combined risk-reducing salpingo-oophorectomy and prophylactic mastectomy resulted in the greatest LE and was cost-effective in most analyses. Despite leading to increased LE and QALYs, combined mammography and breast magnetic resonance imaging (MRI) was less likely to be cost-effective than either mammography or MRI alone, particularly for women over 50 and BRCA2 carriers. Variation in patient compliance to risk management interventions was incorporated in 11/34 studies with the remaining analyses assuming 100% adherence. CONCLUSION Prophylactic surgery and intensive breast screening are effective and cost-effective in models of BRCA carrier risk management. Findings were based predominantly on assuming perfect adherence to recommendations without assessment of the health-care resource use and costs related to engaging patients and maximizing compliance, meaning the real-world impact on clinical outcomes and resource use remains unclear.
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Affiliation(s)
- Lara Petelin
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Alison H Trainer
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Gillian Mitchell
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Paul A James
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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Long J, Evans TG, Bailey D, Lewis MH, Gower-Thomas K, Murray A. Uptake of risk-reducing surgery in BRCA gene carriers in Wales, UK. Breast J 2017; 24:580-585. [PMID: 29286205 DOI: 10.1111/tbj.12978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 02/28/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 11/27/2022]
Abstract
Women who inherit a mutated copy of the BRCA gene have a higher lifetime risk of developing breast cancer. No large epidemiological studies exist looking at BRCA mutation carriers in UK populations. All patients with BRCA1/BRCA2 mutation identified between 1995 and 2015 were included. Individuals were identified from a prospectively gathered data base. Genetics case-notes were obtained and retrospective analysis performed. 581 female BRCA mutation carriers were identified with a median age of 34 (18-81) at the time of testing. Of the 301 women who underwent diagnostic testing (symptomatic) 246 had been diagnosed with breast cancer, 89 with ovarian cancer and 37 had both at time of testing. Median age at diagnostic test was 51 (25-81). 33% of women underwent risk-reducing mastectomies (RRM); median age at surgery 45. This compares with 37% of women in this diagnostic group who underwent Risk-reducing bilateral salpingo-oopherectomies (RRBSO) at a median age of 46. Two hundred and eighty women underwent predictive testing (family history, asymptomatic), median age 36 (18-81). 34% of women in this predictive group underwent RRM, median age 37. There was a 29% uptake of RRBSO (median age 44 years). Fifteen women (5%) developed breast cancer after being tested; none of these had undergone RRS. This unique study of all BRCA mutation carriers in Wales shows considerable variation in uptake of RRS. The decision to undergo RRS is complex and involves a number of factors, including a woman's age and life stage. As BRCA testing becomes more frequent and more gene mutation carriers are identified there will be significant implications for service allocation, screening demands, and provision of risk-reducing surgery for this high-risk patient group.
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Affiliation(s)
| | | | | | | | - Kate Gower-Thomas
- Royal Glamorgan Hospital, Llantrisant, UK.,Breast Test Wales, Cardiff, UK
| | - Alexandra Murray
- All Wales Cancer Genetics Service, University Hospital of Wales, Cardiff, UK
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McVeigh TP, Wiggins J, Ward S, Kemp Z, George AJ. Successful Repatriation of Breast Cancer Surveillance for High-Risk Women to the UK National Health Service Breast Screening Programme. Clin Breast Cancer 2018; 18:282-8. [PMID: 29191429 DOI: 10.1016/j.clbc.2017.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/29/2017] [Accepted: 10/18/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Since April 2013, the UK's National Health Service Breast Screening Programme (NHSBSP) centers have been obliged to provide services for women at the highest risk of breast cancer, including those carrying highly penetrant single gene mutations (BRCA1, BRCA2, TP53). Since then, such individuals previously undergoing surveillance in the Royal Marsden Hospital were referred to their local NHSBSP centers. We aimed to assess patient experience of surveillance provided by local NHSBSP services at 1 and 3 years after repatriation. PATIENTS AND METHODS High-risk gene mutation carriers referred to the NHSBSP for breast cancer surveillance were identified from a departmental database in the Cancer Genetics Unit and invited to complete questionnaires about their experience of surveillance under this new pathway, first in 2014 and again in 2016. RESULTS Three hundred forty-six individuals were invited to participate in 2014, of whom 182 responded (53%). A total of 464 patients were invited in 2016, of whom 246 (53%) completed the second questionnaire. Ninety-four percent of patients with residual breast tissue received some screening at the first (n = 161) and second (n = 185) time points. Ninety-one percent of patients (n = 146) received at least recommended surveillance in the year preceding the initial survey, a proportion decreasing slightly by the second time point (n = 164, 87%). Seventeen percent of individuals required additional diagnostic investigations, with cancers detected in 2%. These proportions remained stable between surveys. CONCLUSION Repatriation of high-risk individuals from Royal Marsden Hospital to NHSBSP centers has been successfully accomplished. Most individuals received appropriate recommended annual surveillance. Further improvements are required to ensure equal and timely provision of recommended surveillance.
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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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Gilbert E, Zabor EC, Stempel M, Mangino D, Heerdt A, Pilewskie M. Differences Among a Modern Cohort of BRCA Mutation Carriers Choosing Bilateral Prophylactic Mastectomies Compared to Breast Surveillance. Ann Surg Oncol 2017; 24:3048-3054. [PMID: 28766223 DOI: 10.1245/s10434-017-5976-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Women with a BRCA mutation have significantly elevated breast cancer risk, which can be reduced by >90% with bilateral prophylactic mastectomy (BPM). We sought to compare a cohort of BRCA mutation carriers choosing BPM versus breast surveillance to better elucidate factors that may impact decision making. METHODS Women with a BRCA mutation were retrospectively identified from a prospectively maintained database. The surveillance cohort (n = 313) consisted of women seen in a high-risk clinic between 2014 and 2016, while the surgery cohort (n = 142) consisted of women who underwent BPM between 2010 and 2016. Clinical and familial factors were compared between the groups. RESULTS Women choosing BPM were more likely to have a BRCA1 than BRCA2 mutation compared with the surveillance group (57 vs. 45%, p = 0.02) and were less likely to have a personal history of ovarian cancer (10 vs. 20%, p = 0.01). Furthermore, women undergoing BPM were more likely to be married (78 vs. 62%, p = 0.01), to have more children (median 2 vs. 1, p < 0.001), and to have undergone a prophylactic oophorectomy (61 vs. 37%, p < 0.001). Women choosing BPM had more first-degree relatives (63 vs. 48%, p = 0.01) or a sister (23 vs. 14%, p = 0.02) with a history of breast cancer and were more likely to have a family member with ovarian cancer under the age of 40 years (9 vs. 4%, p = 0.03). There was no difference in the number of prior breast biopsies or history of atypia/lobular carcinoma in situ. CONCLUSION The decision to undergo BPM appears multifactorial, with gene mutation, family history, and relationships appearing to have the strongest influence on decision making.
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Affiliation(s)
- Elizabeth Gilbert
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Debra Mangino
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Glassey R, O’connor M, Ives A, Saunders C, O’sullivan S, Hardcastle SJ; kConFab Investigators. Heightened perception of breast cancer risk in young women at risk of familial breast cancer. Fam Cancer 2018; 17:15-22. [DOI: 10.1007/s10689-017-0001-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Several medical management approaches have been shown to be effective in preventing breast cancer and detecting it early among women at elevated risk: 1) prophylactic mastectomy; 2) prophylactic oophorectomy; 3) chemoprevention; and 4) enhanced screening routines. To varying extents, however, these approaches are substantially underused relative to clinical practice recommendations. This article reviews the existing research on the uptake of these prevention approaches, the characteristics of women who are likely to use various methods, and the decision-making processes that underlie the differing choices of women. It also highlights important areas for future research, detailing the types of studies that are particularly needed in four key areas: documenting women's perspectives on their own perceptions of risk and prevention decisions; explicit comparisons of available prevention pathways and their likely health effects; the psychological, interpersonal, and social processes of prevention decision making; and the dynamics of subgroup variation. Ultimately, this research could support the development of interventions that more fully empower women to make informed and values-consistent decisions, and to move towards favorable health outcomes.
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Affiliation(s)
- Tasleem J. Padamsee
- Division of Health Services Management & Policy, College of Public Health, The Ohio State University, 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH 43220 USA
| | - Celia E. Wills
- College of Nursing, The Ohio State University, Columbus, OH USA
| | - Lisa D. Yee
- College of Medicine, The Ohio State University, Columbus, OH USA
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Tschernichovsky R, Goodman A. Risk-Reducing Strategies for Ovarian Cancer in BRCA Mutation Carriers: A Balancing Act. Oncologist 2017; 22:450-459. [PMID: 28314837 DOI: 10.1634/theoncologist.2016-0444] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/22/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The objective of this study was to review the role of bilateral salpingo-oophorectomy in BRCA mutation (mBRCA) carriers and alternative interventions in risk reduction of ovarian cancer (OC). MATERIALS AND METHODS A systematic review using PubMed, MEDLINE, EMBASE, and the Cochrane library was conducted to identify studies of different strategies to prevent OC in mBRCA carriers, including bilateral salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, intensive surveillance, and chemoprevention. RESULTS Risk-reducing bilateral salpingo-oophorectomy is an effective intervention, but its associated morbidity is substantial and seems to curtail uptake rates among the target population. Although there is much interest and a strong theoretical basis for salpingectomy with delayed oophorectomy, data on its clinical application are scarce with regard to screening, the use of an algorithmic protocol has recently shown favorable albeit indefinite results in average-risk postmenopausal women. Its incorporation into studies focused on high-risk women might help solidify a future role for screening as a bridge to surgery. The use of oral contraceptives for chemoprevention is well supported by epidemiologic studies. However, there is a lack of evidence for advocating any of the other agents proposed for this purpose, including nonsteroidal anti-inflammatory drugs, vitamin D, and retinoids. CONCLUSION Further studies are needed before salpingectomy with delayed oophorectomy or intensive surveillance can be offered as acceptable, less morbid alternatives to upfront oophorectomy for mBRCA carriers. The Oncologist 2017;22:450-459 IMPLICATIONS FOR PRACTICE: Risk-reducing bilateral salpingo-oophorectomy is currently the most effective method for reducing the risk of ovarian cancer in BRCA mutation (mBRCA) carriers. Unfortunately, it is associated with significant short- and long-term morbidity, stemming from reduced circulating estrogen. In recent years, much research has been devoted to evaluating less morbid alternatives, especially multimodal cancer screening and prophylactic salpingectomy with delayed oophorectomy. This review describes the present state of the art, with the aim of informing the counseling provided to mBRCA carriers on this complicated issue and encouraging additional research to facilitate the incorporation of such alternatives into routine practice.
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Affiliation(s)
| | - Annekathryn Goodman
- Division of Gynecologic Oncology
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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van Driel CMG, Oosterwijk JC, Meijers-Heijboer EJ, van Asperen CJ, Zeijlmans van Emmichoven IA, de Vries J, Mourits MJE, Henneman L, Timmermans DRM, de Bock GH. Psychological factors associated with the intention to choose for risk-reducing mastectomy in family cancer clinic attendees. Breast 2016; 30:66-72. [PMID: 27639031 DOI: 10.1016/j.breast.2016.08.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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: 03/22/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Women seeking counseling because of familial breast cancer occurrence face difficult decisions, such as whether and when to opt for risk-reducing mastectomy (RRM) in case of BRCA1/2 mutation. Only limited research has been done to identify the psychological factors associated with the decision for RRM. This study investigated which psychological factors are related to the intention to choose for RRM. MATERIALS & METHODS A cohort of 486 cancer-unaffected women with a family history of breast cancer completed the following questionnaires prior to genetic counseling: the Cancer Worry Scale, Positive And Negative Affect Scale, Perceived Personal Control Scale, Hospital Anxiety and Depression Scale and State Anxiety Scale and questions regarding socio-demographic characteristics, family history, risk perception and RRM intention. Multivariate logistic regression was used to analyze the relation between psychological factors and women's intention to choose for RRM. RESULTS Factors associated with RRM intention were high positive affect (OR = 1.86, 95%CI = 1.12-3.08), high negative affect (OR = 2.52, 95%CI = 1.44-4.43), high cancer worry (OR = 1.65, 95%CI = 1.00-2.72), high perceived personal control (OR = 3.58, 95%CI = 2.18-5.89), high risk-perception (OR = 1.85, 95%CI = 1.15-2.95) and having children (OR = 2.06, 95%CI = 1.21-3.50). CONCLUSION Negative and positive affects play an important role in the intention for RRM. Furthermore, perceived personal control over the situation is associated with an intention for RRM. In addition to focusing on accurate risk communication, counseling should pay attention to the influence of perceived control and emotions to facilitate decision-making.
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Affiliation(s)
- C M G van Driel
- Department of Obstetrics & Gynecology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
| | - J C Oosterwijk
- Department of Genetics, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - E J Meijers-Heijboer
- Department of Clinical Genetics, VU University Medical Center Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - C J van Asperen
- Department of Clinical Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - I A Zeijlmans van Emmichoven
- Department of Medical Psychology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - J de Vries
- Department of Surgery, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - M J E Mourits
- Department of Obstetrics & Gynecology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - L Henneman
- Department of Clinical Genetics, VU University Medical Center Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - D R M Timmermans
- EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands; Department of Public and Occupational Health, VU University Medical Center Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - G H de Bock
- Department of Epidemiology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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van der Aa JE, Hoogendam JP, Butter ESF, Ausems MGEM, Verheijen RHM, Zweemer RP. The effect of personal medical history and family history of cancer on the uptake of risk-reducing salpingo-oophorectomy. Fam Cancer 2016; 14:539-44. [PMID: 26264902 PMCID: PMC4630248 DOI: 10.1007/s10689-015-9827-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Women with an increased lifetime risk of ovarian cancer are advised to undergo risk-reducing salpingo-oophorectomy (RRSO) to reduce risk of adnexal cancer. We investigated the uptake of RRSO and evaluated the influence of personal medical history of (breast) cancer, risk-reducing mastectomy (RRM) and family history of ovarian and/or breast cancer on the RRSO decision. This single center retrospective observational cohort study was performed in a tertiary multidisciplinary clinic for hereditary cancer of the University Medical Centre Utrecht, The Netherlands. Women ≥35 years old with an estimated lifetime risk of ovarian cancer ≥10%, who had completed childbearing, were eligible for RRSO. Uptake and timing of RRSO were analyzed. Influence of personal medical history and family history on RRSO decision making, were evaluated with logistic regression. The study population consisted of 218 women (45.0% BRCA1 mutation carrier, 28.0% BRCA2 mutation carrier, 27.0% with familial susceptibility) with 87.2% RRSO uptake. The median age at RRSO was 44.5 (range 28-73) years. Of the women undergoing RRSO, 78.3% needed ≤3 consultations to reach this decision. Multivariable analysis showed a significant difference in RRSO uptake for women with a history of RRM [OR 3.66 95% CI (1.12-11.98)], but no significant difference in women with a history of breast cancer [OR 1.38 95% CI (0.50-3.79)], nor with a family history of ovarian and/or breast cancer [OR 1.10 95% CI (0.44-2.76)]. We conclude that RRSO counseling, without the alternative of screening, is effective. The uptake is increased in women with a history of RRM.
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Affiliation(s)
- Jessica E van der Aa
- Department of Gynaecological Oncology, UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jacob P Hoogendam
- Department of Gynaecological Oncology, UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Els S F Butter
- Department of Gynaecological Oncology, UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Margreet G E M Ausems
- Department of Medical Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - René H M Verheijen
- Department of Gynaecological Oncology, UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ronald P Zweemer
- Department of Gynaecological Oncology, UMC Utrecht Cancer Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Ludwig KK, Neuner J, Butler A, Geurts JL, Kong AL. Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review. Am J Surg 2016; 212:660-669. [PMID: 27649974 DOI: 10.1016/j.amjsurg.2016.06.010] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [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: 02/02/2016] [Revised: 03/28/2016] [Accepted: 06/17/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mutations in BRCA1 or BRCA2 genes results in an elevated risk for developing both breast and ovarian cancers over the lifetime of affected carriers. General surgeons may be faced with questions about surgical risk reduction and survival benefit of prophylactic surgery. METHODS A systematic literature review was performed using the electronic databases PubMed, OVID MEDLINE, and Scopus comparing prophylactic surgery vs observation with respect to breast and ovarian cancer risk reduction and mortality in BRCA mutation carriers. RESULTS Bilateral risk-reducing mastectomy provides a 90% to 95% risk reduction in BRCA mutation carriers, although the data do not demonstrate improved mortality. The reduction in ovarian and breast cancer risks using risk-reducing bilateral salpingo-oophorectomy has translated to improvement in survival. CONCLUSIONS Clinical management of patients at increased risk for breast cancer requires consideration of risk, patient preference, and quality of life.
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Affiliation(s)
- Kandice K Ludwig
- Department of Surgery, Indiana University School of Medicine, Carmel, IN, USA
| | - Joan Neuner
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Annabelle Butler
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Jennifer L Geurts
- Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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