Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer

BACKGROUND

Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis.

METHODS

Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated.

RESULTS

A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses.

CONCLUSION

These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.

Understanding the Breast Cancer Experience of Women in East Africa: A Qualitative Study

Background: Breast cancer is one of the leading causes of premature death in women in East Africa. The majority of patients are diagnosed with advanced cancers (stage III and IV) which results in more cancer deaths. Even after a diagnosis of breast cancer, many patients do not complete their treatment. The reasons why delays in diagnosis and treatment occur are multilevel, involving a combination of both patient related factors, such as sociocultural reasons like stigma or fatalism, or the use of alternative medicine. Financial factors play a big role as many patients have to pay out of pocket for their health expenditure. System related factors such as a lack of resources for the diagnosis or treatment, lack of health worker knowledge leading to misdiagnosis with inappropriate treatment and poor referral pathways, also contribute to delays in care. Aim: To understand the experience of breast cancer patients in East Africa, to determine the facilitators and barriers to diagnosis, treatment and follow-up of breast cancer. Methods: 28 patients in Kenya and Tanzania who had completed at least a year of initial treatment were invited to participate in the study. A qualitative exploratory study was done using semistructured, in-depth interviews. Grounded theory was then used to analyze and develop themes that emerged from these narratives. Results: For these patients who had completed at least a year of treatment, the cost of treatment and expenses incurred was a major concern. Family disintegration emerged as a significant theme following cancer diagnosis. There was a prevalence of stigma around breast cancer and patients would not disclose their status to others in the community for fear of being ridiculed, pitied or isolated. A number of patients used alternative medicine resulting in delays in treatment. Family support, support groups and spirituality played a major role in facilitating the completion of initial care and in reducing psychological morbidity. System factors such as poor referral pathways, and inappropriate treatment emerged as minor themes. Conclusion: The sociocultural aspects of breast cancer need to be addressed to ensure comprehensive management of breast cancer patients and completion of treatment. As programs in the region, mainly run by governments, aim to improve the financial access to treatment, it would be critical to include efforts aimed at stigma reduction and interventions focusing on the sociocultural reintegration of these patients.

Abstract P5-19-02: Withdrawn

This abstract was withdrawn by the authors.

Nipple-sparing mastectomy in patients with BRCA1/2 mutations and variants of uncertain significance

BACKGROUND

Nipple-sparing mastectomy (NSM) is associated with improved cosmesis and is being performed increasingly. Its role in BRCA mutation carriers has not been well described. This was a study of the indications for, and outcomes of, NSM in BRCA mutation carriers.

METHODS

BRCA mutation carriers who underwent NSM were identified. Details of patient demographics, surgical procedures, complications, and relevant disease stage and follow-up were recorded.

RESULTS

A total of 177 NSMs were performed in 89 BRCA mutation carriers between September 2005 and December 2013. Twenty-six patients of median age 41 years had NSM for early-stage breast cancer and a contralateral prophylactic mastectomy. Mean tumour size was 1·4 (range 0·1-3·5) cm. Sixty-three patients of median age 39 years had prophylactic NSM, eight of whom had an incidental diagnosis of ductal carcinoma in situ. There were no local or regional recurrences in the 26 patients with breast cancer at a median follow-up of 28 (i.q.r. 15-43) months. There were no newly diagnosed breast cancers in the 63 patients undergoing prophylactic NSM at a median follow-up of 26 (11-42) months. All patients had immediate breast reconstruction. Five patients (6 per cent) required subsequent excision of the nipple-areola complex for oncological or other reasons. Skin desquamation occurred in 68 (38·4 per cent) of the 177 breasts, and most resolved without intervention. Debridement was required in 13 (7·3 per cent) of the 177 breasts, and tissue-expander or implant removal was necessary in six instances (3·4 per cent).

CONCLUSION

NSM is an acceptable choice for patients with BRCA mutations, with no evidence of compromise to oncological safety at short-term follow-up. Complication rates were acceptable, and subsequent excision of the nipple-areola complex was rarely required.

EYA4 is inactivated biallelically at a high frequency in sporadic lung cancer and is associated with familial lung cancer risk

In an effort to identify novel biallelically inactivated tumor suppressor genes (TSG) in sporadic invasive and pre-invasive non-small cell lung cancer (NSCLC) genomes, we applied a comprehensive integrated multi-‘omics approach to investigate patient matched, paired NSCLC tumor and non-malignant parenchymal tissues. By surveying lung tumor genomes for genes concomitantly inactivated within individual tumors by multiple mechanisms, and by the frequency of disruption in tumors across multiple cohorts, we have identified a putative lung cancer TSG, Eyes Absent 4 (EYA4). EYA4 is frequently and concomitantly deleted, hypermethylated and underexpressed in multiple independent lung tumor data sets, in both major NSCLC subtypes, and in the earliest stages of lung cancer. We find not only that decreased EYA4 expression is associated with poor survival in sporadic lung cancers, but EYA4 SNPs are associated with increased familial cancer risk, consistent with EYA4’s proximity to the previously reported lung cancer susceptibility locus on 6q. Functionally, we find that EYA4 displays TSG-like properties with a role in modulating apoptosis and DNA repair. Cross examination of EYA4 expression across multiple tumor types suggests a cell type-specific tumorigenic role for EYA4, consistent with a tumor suppressor function in cancers of epithelial origin. This work shows a clear role for EYA4 as a putative TSG in NSCLC.

Abstract ES6-2: Evolving Trends in Implant Breast Reconstruction

For women undergoing mastectomy, implant breast reconstruction is increasingly common. Over the past 5 years, new trends in implant reconstruction have been evolving. The use of ‘next-generation’ silicone implants, acellular dermal matrices and fat grafting have expanded the range of options available to patients. In addition, for women undergoing both skin-sparing and nipple-sparing mastectomies, there is growing experience with single-stage implant reconstruction (i.e. implant placement directly at the time of mastectomy without use of a tissue expander). Finally, indications for post-mastectomy radiation continue to increase and this has important implications for long-term patient satisfaction with implant reconstruction.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr ES6-2.

ES8-3: Measuring Outcomes in Breast Reconstruction: The Patient Perspective

In breast reconstruction, understanding patients’ perceptions of surgical results is of primary importance. As new reconstructive techniques continue to advance, surgeons and patients require high quality information on key outcomes such as patient satisfaction and quality of life. The need for meaningful data is further accentuated by concerns over healthcare expenditures and the increasing involvement of patients in their own surgical decision-making.

Patient-reported outcome (PRO) measures are questionnaires specifically designed to quantify aspects of outcome such as patient satisfaction and health-related quality of life. When developed and validated according to internationally recognized standards, PRO measures can provide reliable and valid assessment of patient outcomes. Traditionally, PRO measures were used in clinical research alone; however, advances in psychometric methods have now facilitated the development of a new generation of PRO measures that are also useful in clinical care.

This presentation will provide an overview of PRO research in breast reconstruction. The BREAST-Q, a new PRO measure for breast surgery patients, will be highlighted. Physicians will gain the necessary critical appraisal skills to interpret and apply evidence from PRO studies in their own clinical practice. Approaches to routine use of PRO measures in clinical care will also be described.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr ES8-3.

Understanding normality: a qualitative analysis of breast cancer patients concepts of normality after mastectomy and reconstructive surgery

BACKGROUND

As survival rates increase, many people have to adjust to life after cancer. This includes adjusting to life after surgery. While previous research suggests that patients commonly strive to be 'normal' after mastectomy and reconstructive surgery, research surrounding individual perceptions of normality is lacking.

AIM

The aim of this study was to explore concepts of normality within a sample of breast cancer patients eligible for reconstructive surgery following mastectomy.

METHODS

A total of 35 semi structured interviews, with women who had undergone or were about to undergo breast reconstructive surgery following breast cancer, were analysed using thematic analysis.

RESULTS

Four main themes emerged from the data. Women referred to looking normal (appearance); being able to fulfil everyday activities (behaviour); adapting to a new normal (reconstructing normality); and not being ill (health). The importance placed on each area of normality differed between patients. Additionally, patients used different standards to anchor concepts of normality. These included individual standards, social standards and clinical standards.

DISCUSSION

The results indicate that although there are commonalities between patients' concepts of normality, it is important for health care professionals to recognise potential individual differences. This may usefully aid communication and help to manage expectations among patients considering surgical options.

Surgeon perspectives on surgical options for early-stage breast cancer

To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.

Surgical options for the early-stage breast cancer: factors associated with patient choice and postoperative quality of life

Patients with early-stage breast cancer have three surgical options: lumpectomy with radiotherapy, mastectomy alone, and mastectomy with breast reconstruction. Our objective was to compare women in these three groups with respect to demographics, preoperative counseling, postoperative body image, and quality of life. Women having undergone surgery for stage 1 or 2 breast cancer between 1990 and 1995 were selected by random sampling of hospital tumor registries and were mailed a self-administered questionnaire, which included the Medical Outcomes Survey Short Form 36. Patients were stratified into three mutually exclusive groups: lumpectomy with axillary node dissection and radiotherapy, modified radical mastectomy, and modified radical mastectomy with breast reconstruction. In total, 267 of 525 surveys were returned (50.9 percent). Compared with mastectomy patients, breast reconstruction patients were younger (p < 0.001), better educated (p = 0.001), and more likely Caucasian (p = 0.02). Among mastectomy patients, 54.9 percent recalled that lumpectomy had been discussed preoperatively and 39.7 percent recalled discussion of breast reconstruction. Post-operative comfort with appearance was significantly lower for mastectomy patients. The relationship between type of surgery and postoperative quality of life varied with age. Under 55, quality of life was lowest for mastectomy patients on all but two Medical Outcomes Survey Short Form 36 subscales. Over 55, quality of life was lowest for lumpectomy patients on all subscales (p < 0.05 for all subscales except social functioning and role-emotional). Treatment choice may be related to age, race, education, and preoperative counseling. Whereas the effect of breast cancer on a woman's life is complex and individual, the type of surgery performed is a significant variable, whose impact may be related to patient age.