Contralateral prophylactic mastectomy in a rural population: A single-institution experience.

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.

Real de-escalation or escalation in disguise?

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.

La mastectomía como medida de reducción de riesgo de cáncer de mama / Risk-reducing mastectomy in breast cancer

Objetivos: Evaluar las mastectomías reductoras de riesgo realizadas y analizar las indicaciones y resultados según las características individuales, oncológicas y quirúrgicas de nuestras pacientes.MétodosEstudio observacional retrospectivo de todas las mastectomías con reconstrucción inmediata en mamas sanas realizadas desde 2013 a 2019. Se dividieron las pacientes en tres grupos: I) riesgo genético de cáncer de mama, II) cáncer de mama diagnosticado y III) antecedente de cáncer de mama.ResultadosSe realizaron 56 mastectomías reductoras de riesgo a 46 pacientes, 15% grupo I, 50% grupo II y 35% grupo III, pero tras estudios diferidos, 20 pacientes (43%) presentaban mutación genética. La media de edad en este subgrupo fue de 40 años y con predominio de tumores HER2+ (40% frente al 12%, p=0,164). En el grupo III observamos más complicaciones inmediatas (31%, p=0,014) y tardías (69%, p=0,027) relacionadas con la reconstrucción protésica, y más evidente en mamas que tuvieron enfermedad (73% frente al 39% sanas, p=0,002). Se encontró relación entre contractura capsular y la radioterapia postoperatoria (p=0,008) y entre necrosis y radioterapia preoperatoria (p=0,001). Se reintervino al 7% por complicaciones en mastectomías profilácticas. No hemos tenido recidivas locales.ConclusionesConsideramos justificada la mastectomía reductora de riesgo realizada a mujeres jóvenes con mutación genética y a pacientes con cáncer precoz, HER2+ y riesgo familiar. En pacientes ya tratadas por cáncer, el riesgo de complicaciones supera el valor profiláctico de la técnica. La reconstrucción mamaria es la principal responsable de complicaciones postoperatorias y las pacientes deben ser plenamente conscientes de ello. (AU)

Objectives: To evaluate the risk-reducing mastectomies performed and to analyse the indications and results according to the individual, oncological and surgical characteristics of our patients.MethodsRetrospective observational study of all mastectomies with immediate reconstruction in healthy breasts performed from 2013 to 2019. The patients were divided into three groups: I) genetic risk of breast cancer, II) diagnosed breast cancer and III) history of cancer breast.ResultsA total of 56 risk-reducing mastectomies were performed in 46 patients, 15% in group I, 50% in group II and 35% in group III. After deferred studies, 20 (43%) patients had a genetic mutation. This subgroup had an average age of 40 years and a predominance of HER2+ tumours (40% versus 12%, p=0.164). In group III, we observed more immediate (31%, p=0.014) and late (69%, p=0.027) complications related to prosthetic reconstruction, which were more evident in breasts with disease (73% versus 39% healthy, p=0.002). A relationship was found between capsular contracture and postoperative radiotherapy (p=0.008) and between necrosis and preoperative radiotherapy (p=0.001). Reoperation was required in 7% for complications of prophylactic mastectomies. There were no local relapses.ConclusionsWe consider risk-reducing mastectomy to be justified in young women with a genetic mutation and in patients with early cancer, HER2+ and family risk. In patients already treated for cancer, the risk of complications exceeds the prophylactic value of the technique. Breast reconstruction is primarily responsible for postoperative complications and patients should be fully aware of this. (AU)

Mastectomía contralateral profiláctica con reconstrucción inmediata en pacientes con cáncer de mama unilateral sin mutación germinal en BRCA1/2 / Prophylactic contralateral mastectomy with immediate reconstruction in patients with unilateral breast cancer without germline BRCA1/2 mutations

Introducción No existe un consenso sobre las indicaciones de mastectomía contralateral en pacientes diagnosticadas de cáncer de mama unilateral sin mutación germinal en BRCA1/2. Estudios previos han identificado algunos factores que pueden influir en la toma de la decisión dependientes del tumor, como el tamaño o histología, de la paciente, como la edad, y de la cirugía como la posibilidad de realizar una reconstrucción inmediata o la experiencia del cirujano.MétodosEstudio retrospectivo de una cohorte de 176 pacientes diagnosticadas de CM entre 2010 y 2016 a las que se les realizó cirugía mamaria. Se ha analizado la asociación de características del tumor y de la paciente con la toma de decisión de realizar mastectomía contralateral (MC) o no-MC. Asimismo, se han analizado los datos relacionados con la cirugía y la recurrencia por grupos mediante la curva de incidencia acumulada y el test de Gray.ResultadosEl número de MC se ha incrementado en nuestro centro. No hemos encontrado diferencias significativas en el desarrollo de complicaciones posquirúrgicas entre los 2 grupos de pacientes, pero sí en la estancia hospitalaria, siendo superior para MC. También hemos observado diferencias entre ambas cohortes en edad y tipo de tumor, siendo la MC más frecuente en aquellas pacientes más jóvenes y subtipo luminal A. Hemos hallado diferencias en la incidencia acumulada de recidiva entre ambos subgrupos (p=0,034).ConclusionesEn nuestra cohorte la MC se realiza más frecuentemente en pacientes más jóvenes y con cáncer de mama luminal A.(AU)

Introduction There is no consensus on the indications for contralateral mastectomy (CM) in patients diagnosed with unilateral breast cancer without germline BRCA1/2 mutations. Prior studies have identified some factors that could influence decision-making. These factors include tumoural size and histological type; patient-related factors, such as age; and surgical factors such as the possibility of immediate reconstruction and the surgeon's experience.MethodsRetrospective study of a cohort of 176 patients diagnosed with breast cancer between 2010 and 2016 who underwent breast surgery. We analysed the association between tumoural and patient-related characteristics with the decision to perform CM or not. We also analysed data related to surgery and recurrence by groups by using the cumulative incidence curve and the Gray test.ResultsThe number of CM has increased in our centre. We found no significant differences in the occurrence of post-surgical complications between the two patient groups but length of hospital stay was higher in CM. We also found differences between the two cohorts in age and tumoural type, with CM being more frequent in younger patients and those with luminal A subtype. Differences were found in the cumulative incidence of recurrence between subgroups (p=0.034).ConclusionsIn our cohort, CM was more frequent in younger patients and in those with luminal A breast cancer.(AU)

Quality of Life after Bilateral and Contralateral Prophylactic Mastectomy with Implant Reconstruction.

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.

Randomized trial of proactive rapid genetic counseling versus usual care for newly diagnosed breast cancer patients.

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.

Ductal Carcinoma In Situ: Treatment Update and Current Trends.

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.

Immediate reconstruction following nipple-sparing mastectomy: one option for young breast cancer patients with early stage disease.

The article entitled "Application of immediate breast reconstruction with silicon prosthetic implantation following bilateral mammary gland excision in treatment of young patients with early breast cancer" published in Journal of Thoracic Disease, examined the oncologic and cosmetic outcomes of the aforementioned procedures. We aimed to describe the unique circumstances of young breast cancer patients with early stage disease and highlight the multitude of surgical treatment and reconstructive options available to these patients.