1
|
Clegg DJ, Whiteaker EN, Salomon BJ, Gee KN, Porter CG, Mazonas TW, Heidel RE, Brooks AJ, Bell JL, Boukovalas S, Lloyd JM. Contralateral prophylactic mastectomy in a rural population: A single-institution experience. Surg Open Sci 2024; 18:70-77. [PMID: 38435489 PMCID: PMC10905041 DOI: 10.1016/j.sopen.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Background The incidence of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer (UBC) has continued to increase, despite an absent survival benefit except in populations at highest risk for developing contralateral breast cancer (CBC). CPM rates may be higher in rural populations but causes remain unclear. A study performed at our institution previously found that 21.8 % of patients with UBC underwent CPM from 2000 to 2009. This study aimed to evaluate the CPM trend at a single institution serving a rural population and identify the CPM rate in average-risk patients. Methods Retrospective review of patients who underwent mastectomies for UBC at our institution from 2017 to 2021 was performed. Analysis utilized frequencies and percentages, descriptive statistics, chi-square, and independent sample t-tests. Results A total of 438 patients were included, of whom 64.4 % underwent bilateral mastectomy for UBC (CPM). Patients who underwent CPM were significantly younger, underwent genetic testing, had germline pathogenic variants, had a family history of breast cancer, had smaller tumors, underwent reconstruction, and had more wound infections. Of CPM patients, 50.4 % had no identifiable factors for increased risk of developing CBC. Conclusions The rate of CPM in a rural population at a single institution increased from 21.8 % to 64.4 % over two decades, with an average-risk CPM rate of 50.4 %. Those that undergo CPM are more likely to undergo reconstruction and have more wound infections. Identifying characteristics of patients undergoing CPM in a rural population and the increased associated risks allows for a better understanding of this trend to guide conversations with patients. Key message This study demonstrates that the rate of contralateral prophylactic mastectomy for unilateral breast cancers performed at a single institution serving a largely rural population has nearly tripled over the last two decades, with half of these patients having no factors that increase the risk for developing contralateral breast cancers. Contralateral prophylactic mastectomy was significantly associated with smaller tumors, younger age, genetic testing, germline pathogenic variants, family history of breast cancer, breast reconstruction, and increased wound infections.
Collapse
Affiliation(s)
- Devin J. Clegg
- University of Tennessee Graduate School of Medicine, Department of Surgery, Knoxville, TN, United States of America
| | - Erica N. Whiteaker
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, United States of America
| | - Brett J. Salomon
- University of Tennessee Graduate School of Medicine, Department of Surgery, Knoxville, TN, United States of America
| | - Kaylan N. Gee
- University of Tennessee Graduate School of Medicine, Department of Surgery, Knoxville, TN, United States of America
| | - Christopher G. Porter
- University of Tennessee Graduate School of Medicine, Department of Surgery, Knoxville, TN, United States of America
| | - Thomas W. Mazonas
- University of Tennessee Graduate School of Medicine, Department of Surgery, Knoxville, TN, United States of America
| | - R. Eric Heidel
- University of Tennessee Graduate School of Medicine, Department of Surgery, Division of Biostatistics, Knoxville, TN, United States of America
| | - Ashton J. Brooks
- University of Tennessee Graduate School of Medicine, Department of Surgery, Division of Surgical Oncology, Knoxville, TN, United States of America
| | - John L. Bell
- University of Tennessee Graduate School of Medicine, Department of Surgery, Division of Surgical Oncology, Knoxville, TN, United States of America
| | - Stefanos Boukovalas
- University of Tennessee Graduate School of Medicine, Department of Surgery, Division of Plastic & Reconstructive Surgery, Knoxville, TN, United States of America
| | - Jillian M. Lloyd
- University of Tennessee Graduate School of Medicine, Department of Surgery, Division of Surgical Oncology, Knoxville, TN, United States of America
| |
Collapse
|
2
|
Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast 2023; 69:249-257. [PMID: 36898258 PMCID: PMC10017412 DOI: 10.1016/j.breast.2023.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
The past two decades have seen an unprecedented trend towards de-escalation of surgical therapy in the setting of early BC, the most prominent examples being the reduction of re-excision rates for close surgical margins after breast-conserving surgery and replacing axillary lymph node dissection by less radical procedures such as sentinel lymph node biopsy (SLNB). Numerous studies confirmed that reducing the extent of surgery in the upfront surgery setting does not impact locoregional recurrences and overall outcome. In the setting of primary systemic treatment, there is an increased use of less invasive staging strategies reaching from SLNB and targeted lymph node biopsy (TLNB) to targeted axillary dissection (TAD). Omission of any axillary surgery in the presence of pathological complete response in the breast is currently being investigated in clinical trials. On the other hand, concerns have been raised that surgical de-escalation might induce an escalation of other treatment modalities such as radiation therapy. Since most trials on surgical de-escalation did not include standardized protocols for adjuvant radiotherapy, it remains unclear, whether the effect of surgical de-escalation was valid in itself or if radiotherapy compensated for the decreased surgical extent. Uncertainties in scientific evidence may therefore lead to escalation of radiotherapy in some settings of surgical de-escalation. Further, the increasing rate of mastectomies including contralateral procedures in patients without genetic risk is alarming. Future studies of locoregional treatment strategies need to include an interdisciplinary approach to integrate de-escalation approaches combining surgery and radiotherapy in a way that promotes optimal quality of life and shared decision-making.
Collapse
Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, Madrid, Spain
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital Augsburg, Augsburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | | | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Interdisciplinary Breast Center, Die Filderklinik, Filderstadt, Germany.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Schwartz MD, Peshkin BN, Isaacs C, Willey S, Valdimarsdottir HB, Nusbaum R, Hooker G, O'Neill S, Jandorf L, Kelly SP, Heinzmann J, Zidell A, Khoury K. Randomized trial of proactive rapid genetic counseling versus usual care for newly diagnosed breast cancer patients. Breast Cancer Res Treat 2018; 170:517-524. [PMID: 29611029 PMCID: PMC6026034 DOI: 10.1007/s10549-018-4773-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Breast cancer patients who carry BRCA1/BRCA2 gene mutations may consider bilateral mastectomy. Having bilateral mastectomy at the time of diagnosis not only reduces risk of a contralateral breast cancer, but can eliminate the need for radiation therapy and yield improved reconstruction options. However, most patients do not receive genetic counseling or testing at the time of their diagnosis. In this trial, we tested proactive rapid genetic counseling and testing (RGCT) in newly diagnosed breast cancer patients in order to facilitate pre-surgical genetic counseling and testing. METHODS We recruited newly diagnosed breast cancer patients at increased risk for carrying a BRCA1/2 mutation. Of 379 eligible patients who completed a baseline survey, 330 agreed to randomization in a 2:1 ratio to RGCT (n = 220) versus UC (n = 108). Primary outcomes were genetic counseling and testing uptake and breast cancer surgical decisions. RESULTS RGCT led to higher overall (83.8% vs. 54.6%; p < 0.0001) and pre-surgical (57.8% vs. 38.7%; p = 0.001) genetic counseling uptake compared to UC. Despite higher rates of genetic counseling, RGCT did not differ from UC in overall (54.1% vs. 49.1%, p > 0.10) or pre-surgical (30.6% vs. 27.4%, p > 0.10) receipt of genetic test results nor did they differ in uptake of bilateral mastectomy (26.6% vs. 21.8%, p > 0.10). CONCLUSIONS Although RGCT yielded increased genetic counseling participation, this did not result in increased rates of pre-surgical genetic testing or impact surgical decisions. These data suggest that those patients most likely to opt for genetic testing at the time of diagnosis are being effectively identified by their surgeons.
Collapse
Affiliation(s)
- Marc D Schwartz
- Georgetown Lombardi Comprehensive Cancer, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, The Harris Building, Washington, DC, 20007, USA.
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA.
| | - Beth N Peshkin
- Georgetown Lombardi Comprehensive Cancer, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, The Harris Building, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
| | - Claudine Isaacs
- Georgetown Lombardi Comprehensive Cancer, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, The Harris Building, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
| | - Shawna Willey
- Georgetown Lombardi Comprehensive Cancer, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, The Harris Building, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
| | - Heiddis B Valdimarsdottir
- Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychology, Reykjavik University, Reykjavik, Iceland
| | - Rachel Nusbaum
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | | | - Suzanne O'Neill
- Georgetown Lombardi Comprehensive Cancer, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, The Harris Building, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, Washington, DC, USA
| | - Lina Jandorf
- Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jessica Heinzmann
- Atlantic Health Services, Carol G. Simon Cancer Center, Summit, NJ, USA
| | - Aliza Zidell
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Katia Khoury
- Georgetown Lombardi Comprehensive Cancer, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, The Harris Building, Washington, DC, 20007, USA
| |
Collapse
|
5
|
Abstract
Ductal carcinoma in situ (DCIS) traditionally has been managed through various combinations of surgery, radiation, and endocrine therapy. However, concern for under- or over-treatment of DCIS has led many surgeons to question historically standardized approaches and instead begin to tailor treatment based on individual prognostic indicators. Recent and ongoing clinical trials have investigated the potential for active surveillance in DCIS, the possibility of eliminating radiation therapy (RT), and ways in which adjuvant systemic therapy may be refined. This review will summarize the current trends in the treatment of DCIS, as well as highlight the most pertinent clinical trials that are shaping management today.
Collapse
Affiliation(s)
- Katrina B Mitchell
- Breast Surgical Oncology, MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, TX, 77030, USA.
| | - Henry Kuerer
- Breast Surgical Oncology, MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, TX, 77030, USA.
| |
Collapse
|