Abstract
BackgroundFamily history of breast cancer is associated with an increased risk of contralateral breast cancer (CBC) even in the absence of mutations in the breast cancer susceptibility genes BRCA1/2. We compared quality-adjusted survival after contralateral prophylactic mastectomy (CPM) with surveillance only (no CPM) among women with breast cancer incorporating the degree of family history.MethodsWe created a microsimulation model for women with first-degree, second-degree, and no family history treated for a stage I, II, or III estrogen receptor (ER)-positive or ER-negative breast cancer at the ages of 40, 50, 60, and 70. The model incorporated a 10-year posttreatment period for risk of developing CBC and/or dying of the primary cancer or CBC. For each patient profile, we used 100,000 microsimulation trials to estimate quality-adjusted life expectancy for the clinical strategies CPM and no CPM.ResultsCPM showed minimal improvement on quality-adjusted life expectancy among women age 50–60 with no or a unilateral first-degree or second-degree family history (decreasing from 0.31 to –0.06 quality-adjusted life-years (QALYs)) and was unfavorable for most subgroups of women age 70 with stage III breast cancer regardless of degree of family history (range –0.08 to –0.02 QALYs). Sensitivity analysis showed that the highest predicted benefit of CPM assuming 95 % risk reduction in CBC was 0.57 QALYs for a 40-year-old woman with stage I breast cancer who had a first-degree relative with bilateral breast cancer.ConclusionsWomen age 40 with stage I breast cancer and a first-degree relative with bilateral breast cancer have a QALY benefit from CPM similar to that reported for BRCA1/2 mutation carriers. For most subgroups of women, CPM has a minimal to no effect on quality-adjusted life expectancy, irrespective of family history of breast cancer.
Highlights
History of breast cancer is associated with an increased risk of contralateral breast cancer (CBC) even in the absence of mutations in the breast cancer susceptibility genes Breast cancer 1 or gene (BRCA1/2)
Several epidemiologic studies have shown that the frequency of contralateral prophylactic mastectomy (CPM) is higher among women with a family history of breast cancer [15, 16] and among women undergoing genetic testing even if they test negative for a mutation in BRCA1/2 [17, 18]
Effect of CPM on life expectancy by degree of family history of breast cancer CPM was associated with gains (0.02–0.82 years) in life expectancy for all patient subgroups (Table 2)
Summary
History of breast cancer is associated with an increased risk of contralateral breast cancer (CBC) even in the absence of mutations in the breast cancer susceptibility genes BRCA1/2. We compared quality-adjusted survival after contralateral prophylactic mastectomy (CPM) with surveillance only (no CPM) among women with breast cancer incorporating the degree of family history. Despite the minimal survival benefit of contralateral prophylactic mastectomy (CPM) and a declining incidence of contralateral breast cancer (CBC) [1] since 1998, the frequency of CPM has increased in the United States among women with sporadic, unilateral breast cancer [2, 3]. For highrisk groups (i.e., women with a BRCA1/2 mutation), CPM has been shown to be cost-effective compared with surveillance in terms of life expectancy [11]. History of breast cancer is considered to be an important risk factor for developing CBC even among women without mutations in the BRCA1/2 breast cancer susceptibility gene [12, 13]. The survival benefit of CPM in relation to family history of breast cancer, taking into consideration age, stage, and estrogen receptor (ER) status, has not been determined
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