Contralateral Prophylactic Mastectomy Research Articles

Types of Breast Cancer Surgery and Breast Reconstruction.

Background: Breast cancer continues to be a significant diagnostic and therapeutic problem. Mastectomy is still a frequently used treatment method, but its form is changing with progress in medicine. Methods: We have described important types of surgical treatments for breast cancer, such as modified radical mastectomy, breast-conserving surgery, contralateral prophylactic mastectomy, and robotic mastectomy. Breast reconstruction is also a very important element of treatment because it directly affects the mental state of patients after the procedure. We have also described types of breast reconstruction, such as implants, acellular dermal matrices, autologous reconstruction, robotic breast reconstruction, and fat grafting. Results: The aim of our study was to compare available types of surgical treatment for breast cancer and breast reconstruction to help tailor personalized treatment to patients.

Can contralateral prophylactic mastectomy and oophorectomy increase survival in BRCA-related breast cancer? Results from the Italian MUTina study

IntroductionIn the Emilia-Romagna region of Italy, a unique Hub and Spoke model was adopted to recognize BRCA-related breast cancer (BC) patients. Characteristics and outcomes of tumors identified by this model will be presented. MethodsThis multicenter retrospective cohort study involved patients diagnosed with BRCA-related BC identified in the Emilia-Romagna region between January 2000 and December 2013. Seven provinces collected data on patient and tumor characteristics; clinical and gene testing information were also registered. Comparisons between BRCA1 and BRCA2 BC were performed. To balance different variants to identify significant predictors of survival, an inverse probability of treatment weighting (IPTW) analysis on Cox regression was conducted. ResultsFrom 2000 to 2013, 284 BRCA-related BC were registered (171 BRCA1, 110 BRCA2, and 3 BRCA1 and BRCA2). BRCA1 were diagnosed at an earlier stage compared to BRCA2 (50.1 % vs 30 %, respectively, in stage I, P = 0.0015). BRCA2 patients underwent more up-front surgery (85 % vs. 74.9 %, P = 0.049) and less chemotherapy (69.1 % vs 88.9 %, P = 0.004) than BRCA1 patients. At 11.8 years median follow-up, BRCA1 patients developed more second contralateral BC (P = 0.09), while BRCA2 had more visceral relapses (P = 0.013). No differences in overall survival (OS) between BRCA1 and BRCA2 patients (P = 0.07) were found. An advantage in OS was independently seen for patients who underwent contralateral prophylactic mastectomy (P = 0.0001) and oophorectomy (P < 0.0001). ConclusionsIn conclusion, adopting a homogeneous regional framework provides important information about prevention and treatment strategies of BRCA-related BC and suggests using maximal surgery to improve OS.

Impact of contralateral prophylactic mastectomy on survival outcomes in patients with unilateral breast cancer: A systematic review and meta-analysis.

To synthesize contemporary evidence of the impact of contralateral prophylactic mastectomy (CPM) on survival outcomes in patients with unilateral breast cancer (UBC). PubMed, EMBASE and Scopus databases were searched for observational studies published up to November 15, 2023. Random-effects model was used to obtain pooled effect estimates that were reported as hazards ratio (HR) with 95% confidence intervals (CI). The outcomes of interest were overall survival (OS), breast cancer-specific survival (BCSS), recurrence free survival (RFS) and risk of contralateral breast cancer (CBC). Twenty-one studies were included. Most studies had a retrospective design. CPM was associated with significant improvement of OS (HR 0.80, 95% CI: 0.75, 0.85), BCCS (HR 0.82, 95% CI: 0.74, 0.90), and RFS (HR 0.72, 95% CI: 0.60, 0.86) and significantly reduced risk of CBC (HR 0.05, 95% CI: 0.03, 0.09) in patients with UBC. No evidence of publication bias was detected. Our results provide strong evidence supporting the positive impact of CPM on survival outcomes in patients with UBC. Further research and long-term follow-up studies are warranted to validate these findings.

Post mastectomy reconstruction choice: Do race and ethnicity play a role?

1586 Background: The choice regarding reconstruction after mastectomy is based on multiple factors. We hypothesized that race and ethnicity are associated with decision making regarding reconstruction and choice for bilateral mastectomy among a diverse patient population with equal access to reconstructive options. Methods: A retrospective cohort study was performed of patients who underwent mastectomy with or without reconstruction for cancer or prophylaxis from 1/1/2019-12/31/2020 within a single health care system. Clinical and demographicfeatures were recorded. Study endpoints included reconstruction and contralateral prophylactic mastectomy (CPM) choice. Chi square and logistic regression analyses were performed with hypotheses tested at 5% significance level. Results: A total of 663 patients underwent mastectomy for cancer or prevention. Mean age was 54 (range: 24-93) and median BMI 25 (15-58). The majority of women included identified as Non-Hispanic White (NHW) (52%), with other women identifying as Hispanic, Asian, Non-Hispanic Black (NHB), or Other (Table). Of the total cohort, 647 (98%) patients had surgery for cancer, while 16 (2%) had surgery for prophylaxis. Among those with unilateral cancer (N=602, 91%), NHW women were more likely to get CPM (OR 2.12, p&lt;.001), while NHB (OR 0.58, p=.02) and Asian women (OR 0.47, p=.01) were less likely to choose CPM. Asian women were less likely to undergo reconstruction compared to non-Asian women (OR=0.42, p=.01), while Hispanic women were almost twice as likely to undergo reconstruction compared to non-Hispanic women (OR 1.93, p=.016). Hispanic women were more likely to undergo a DIEP flap (OR 2.77, p &lt;.001), while NHW women were more likely to choose implant reconstruction (OR 2.35, p&lt;.001). Conclusions: In our hospital system, choice for reconstruction or CPM was found to differ based on race and ethnicity. NHW women were more likely to choose CPM and undergo implant-based reconstruction, Asian women were more likely to forgo reconstruction, and Hispanics were more likely to undergo DIEP flaps. Future analysis in this cohort will include other factors such as BMI, insurance status, religion, marital status, and employment status.[Table: see text]

A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction.

Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

"Peace of Mind" After Mastectomy: A Scoping Review.

Many women eligible for breast conservation therapy (BCT) elect unilateral mastectomy (UM) with or without contralateral prophylactic mastectomy (CPM) and cite a desire for "peace of mind." This study aimed to characterize how peace of mind is defined and measured and how it relates to surgical choice. Nine databases were searched for relevant articles through 8 October 2023, and data were extracted from articles meeting the inclusion criteria. The inclusion criteria were met by 20 studies.Most were prospective cohort studies (65%, 13/20). In the majority of the studies (72%, 13/18), Non-Hispanic white/Caucasian women comprised 80 % or more of the study's sample. Almost half of the studies used the phrase "peace of mind" in their publication (45%, 9/20), and few directly defined the construct (15%, 3/20). Instead, words representing an absence of peace of mind were common, specifically, "anxiety" (85%, 17/20), "fear" (75%, 15/20), and "concern" (75%, 15/20). Most of the studies (90%, 18/20) measured peace of mind indirectly using questionnaires validated for anxiety, fear, worry, distress, or concern, which were administered at multiple postoperative time points (55%, 11/20). Most of the studies (95%, 18/19) reported at least one statistically significant result showing no difference in peace of mind between BCT, UM, and/or CPM at their latest time of assessment. Peace of mind is largely framed around concepts that suggest its absence, namely, anxiety, fear, and concern. Existing literature suggests that peace of mind does not differ among average-risk women undergoing BCT, UM, or CPM. Shared surgical decisions should emphasize at least comparable emotional and/or psychosocial well-being between CPM and breast conservation.

Timing of Autologous Tissue Breast Reconstruction Does Not Affect Free Flap Failure.

This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction.

Abstract PO5-22-10: Are contralateral prophylactic mastectomy rates impacted by ASBrS guidelines to offer germline genetic testing to all patients with breast cancer? Results from a large, prospective, single-institution cohort

Abstract Background: It is unclear whether the release of the American Society of Breast Surgeons’ (ASBrS) guideline to offer germline genetic testing to all patients with breast cancer impacted contralateral prophylactic mastectomy (CPM) rates. The objective of this study was to describe trends of germline testing and CPM rates, and to determine predictors of CPM uptake. Methods: This is a retrospective review of two prospectively maintained single institutional databases: Dana-Farber/Brigham Cancer Center’s surgical database, merged with Dana-Farber Cancer Institute’s Genetics and Prevention database. Trends in germline testing and CPM rates were described, in relation to the February 2019 ASBrS guideline release, and a multivariable logistic regression model was used to determine factors associated with CPM utilization. Patients with unilateral stage 0-III breast cancer who underwent surgery between January 2016 and July 2020 were included. Patients were considered “tested” if they underwent germline genetic testing and results were disclosed before their index operation. CPM was defined as contralateral mastectomy performed at index operation or anytime thereafter, excluding mastectomy for a new contralateral breast cancer event. Results: Among 6,064 women in the cohort, 2,455 (40.5%) had germline genetic testing before their index surgery. Rates of testing significantly increased over the study period from 33.7% in 2016 to 64.9% in 2020 (p&amp;lt; 0.001). A total of 783/6,064 (12.9%) patients underwent CPM which was 40.7% (783/1,926) of the patients who underwent mastectomy. The CPM rate was 13.3% before the guideline release (2016 – January 2019) and 12.5% after (February 2019 – 2020). There was no significant change in CPM rate over time (p=0.527), including before (p=0.380) and after (p=0.220) the 2019 guideline release. The following factors were associated with increased CPM rates on multivariable logistic regression: identification of a pathogenic/likely pathogenic variant in a breast cancer predisposition gene (Adjusted Odds Ratio [Adj. OR] 24.43), genetic testing with a negative test result (Adj. OR 1.52), number of relatives with breast/ovarian cancer (Adj. OR 1.18 and 1.39, respectively for each additional relative), younger age (Adj. OR 0.97 if pre-menopausal, 0.91 if post-menopausal, for each year decrement), and cT2-3 tumors (Adj. OR 1.53 and 1.94, respectively as compared to other cT stages); all p&amp;lt; 0.05. Conclusions: Despite increasing germline genetic testing rates, CPM rates were stable over time, indicating that offering genetic testing to more patients does not increase CPM rates in our experience. Selection bias is most certainly contributing to the apparent association between CPM and genetic testing, even if there is a negative test result, as the classic indications for genetic testing are similar to those for CPM. Citation Format: Anna Weiss, Stephen Knapp, Danielle Braun, Brenna Barton, Monica McGrath, Samantha Stokes, Alison Laws, Laura Warren, Stefania Morganti, Filipa Lynce, Brittany Bychkovsky, Huma Rana, Dillon Davis, Jill Stopfer, Judy Garber, Tari King. Are contralateral prophylactic mastectomy rates impacted by ASBrS guidelines to offer germline genetic testing to all patients with breast cancer? Results from a large, prospective, single-institution cohort [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-22-10.

Abstract PO1-08-10: Impact of Oncologist-Led Genetic Counseling and Testing on Prophylactic Mastectomy Rates Among Multi-Ethnic Women with Operable Breast Cancer

Abstract Introduction: Approximately 5-10% of breast cancers are attributed to an inherited pathogenic variant (PV) in breast cancer predisposition genes, such as BRCA1 and BRCA2. Identifying women with hereditary breast cancer syndromes is critical to inform risk-appropriate screening and prevention strategies. For example, contralateral prophylactic mastectomy (CPM) has been shown to reduce the risk of new breast primaries without a demonstrated survival benefit. In a prior study, we found that women with pathogenic/likely pathogenic (P/LP) variants were over four times more likely to undergo CPM compared to those with benign/likely benign (B/LB) variants. In recent years due to expanded indications for genetic testing and social distancing during the COVID-19 pandemic, oncologist-led genetic testing and telehealth genetic counseling has gradually replaced in-person genetic counseling visits. We aimed to understand how changes in the delivery of genetic counseling and testing services impacted CPM rates among multi-ethnic women with operable breast cancer in the post COVID-19 period. Methods: We conducted a retrospective cohort study among 1,080 women diagnosed with unilateral breast cancer who underwent germline genetic testing between 2013 and 2022 at Columbia University Irving Medical Center (CUIMC) in New York, NY. The pre COVID-19 period was defined as 2013-2019 and the post COVID-19 period as 2020-2022. Demographics, including age, race/ethnicity and marital status, and clinical characteristics, such as year of diagnosis, breast cancer stage, tumor hormone receptor status, family history of breast cancer, and genetic test results, were extracted from the electronic health record (EHR). We used univariable and multivariable logistic regression analyses to estimate the odds ratio (OR) and 95% confidence interval (95% CI) associated with each variable and receipt of CPM. Results: Among 1080 evaluable women, mean age at diagnosis was 51.2 years old (SD, 12.3) with 39.6% non-Hispanic White, 27.8% Hispanic, 11.4% non-Hispanic Black, 9.0% Asian, and 12.2% multi-racial/other. Within the overall study population, 12.1% of women had P/LP variants and 21.4% had variants of unknown significance (VUS) results. Non-Hispanic Whites and Blacks had the highest frequency of P/LP variants, whereas VUS results were more common among Hispanics and Asians (see Table). Twenty-three percent of women in the study population underwent CPM. In multivariable analysis, younger age at diagnosis, more advanced stage breast cancer, family history of breast cancer, Hispanic race and P/LP results on germline genetic testing were associated with increased CPM rates. Hispanic women were over 60% more likely to undergo CPM compared to non-Hispanic White women (adjusted OR=1.63, 95% CI=1.07-2.47). No significant change in CPM rates was observed in the post-COVID era compared to the pre-COVID era. Conclusion: We aimed to understand how the transition to telehealth and oncologist-led genetic testing affected CPM rates. Although we did not observe a change in CPM rates in the post-COVID era, Hispanic women had significantly more VUS results and were over 60% more likely to undergo CPM compared to non-Hispanic White women. In future studies, we hope to improve risk communication of genetic test results and the risks and benefits of CPM, particularly in vulnerable and underserved populations. Table 1 Genetic testing results and rates of contralateral prophylactic mastectomy stratified by race/ethnicity in women diagnosed with operable breast cancer and undergoing germline genetic testing from 2013-2022 at Columbia University Irving Medical Center, New York, NY Citation Format: Alissa Michel, Kelly Luo, Vicky Ro, Matthew Fine, Meghna Trivedi, Wendy Chung, Roshni Rao, Tarsha Jones, Elana Levinson, Carrie Koval-Burt, Donna Russo, Ilana Chilton, Rita Kukafka, Katherine Crew. Impact of Oncologist-Led Genetic Counseling and Testing on Prophylactic Mastectomy Rates Among Multi-Ethnic Women with Operable Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-08-10.

Abstract GS02-04: Surgical Treatment of Women with Breast Cancer and a BRCA1 Mutation: An International Analysis of the Impact of Bilateral Mastectomy on Survival

Abstract Background: Women with breast cancer and a BRCA1 mutation face a high risk of contralateral breast cancer. For this reason, many women with a unilateral breast cancer opt for bilateral mastectomies. Some will have a contralateral prophylactic mastectomy as a second surgery. However, it is not clear to what extent this operation impacts breast cancer mortality. The objective of the current study was to evaluate the differences in survival by surgical treatment in an international cohort of women with a BRCA1 mutation and unilateral breast cancer. Methods: Eligible participants were identified from a large international cohort of women with breast cancer and a BRCA1 mutation, from 26 collaborating centres. Patients with DCIS and stage IV breast cancer were excluded. Patients with synchronous bilateral cancer were excluded. Demographic data were patient reported and clinical and treatment data were collected from medical records. Women were followed from date of breast cancer diagnosis to either date of last follow-up or date of death. Results: There were 2482 eligible participants from 26 centres from 11 countries. The mean age of breast cancer diagnosis was 43.1 years (range 18-70 years). Among those who had a unilateral mastectomy or lumpectomy, the risk of contralateral breast cancer at 20 years was 27.5%. After experiencing a contralateral cancer the hazard ratio for breast cancer death was 2.14 (95%CI 1.43-3.18), P=0.0002. The fifteen-year breast cancer specific survival in the entire cohort was 82.9%. The survival was 78.7% for those who had a unilateral mastectomy, 86.2% for those who had a lumpectomy, and 88.7% for those who had bilateral mastectomies. 529 of the women who initially underwent a unilateral surgery subsequently had a contralateral or bilateral preventive mastectomy in the follow up period. 529 of the women with unilateral surgery had a contralateral or bilateral preventive mastectomy in the follow up period. After adjusting for age of diagnosis, tumor size, nodal status, chemotherapy (yes/no) and preventive mastectomy (time dependent) the hazard ratio for breast cancer mortality for bilateral surgery versus unilateral surgery was 0.78 (95% CI 0.55-1.13), p = 0.19. Discussion: Women with a BRCA1 mutation and breast cancer who develop a contralateral breast cancer have double the risk of mortality compared to women who do not develop contralateral breast cancer. We observed a small non-significant reduction in mortality for those who had bilateral mastectomies as initial treatment, but the cohort will require longer follow up for definitive results. Women with a BRCA1 mutation should be counselled on the risks of contralateral breast cancer and make surgical decisions with this knowledge. Citation Format: Kelly Metcalfe, Jan Lubinski, Jana Soukupová, Rinat Bernstein-Molho, Mina Lee, Evans Gareth, Arvids Irmejs, Robert Fruscio, Cynthia Villareal Garza, Joanne Ngeow, Jennifer Plichta, Rinat Yerushalmi, Steven Narod. Surgical Treatment of Women with Breast Cancer and a BRCA1 Mutation: An International Analysis of the Impact of Bilateral Mastectomy on Survival [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr GS02-04.

Current Status of Contralateral Prophylactic Mastectomy: Investigating Structural Racial Disparity.

Contralateral prophylactic mastectomy (CPM) remains a personal decision, influenced by psychosocial factors, including cosmesis and peace of mind. Although use of CPM is disproportionately low among Black patients, the degree to which these disparities are driven by patient- vs hospital-level factors remains unknown. Patients undergoing mastectomy for nonmetastatic ductal or lobular breast cancer were tabulated using the National Cancer Database from 2004 to 2020. The primary endpoint was receipt of CPM. Multivariable logistic regression models were constructed with interaction terms between Black-serving hospital (BSH) status and patient race to evaluate associations with CPM. Cox proportional hazard models were used to evaluate long-term survival. Of 597,845 women studied, 70,911 (11.9%) were Black. After multivariable adjustment, Black race (adjusted odds ratio 0.65, 95% CI 0.64 to 0.67) and treatment at BSH (adjusted odds ratio 0.84, 95% CI 0.83 to 0.85) were independently linked to lower odds of CPM. Although predicted probability of CPM was universally lower at higher BSH, Black patients faced a steeper reduction compared with White patients. Receipt of CPM was linked to improved survival (hazard ratio [HR] 0.84, 95% CI 0.83 to 0.86), whereas Black race was associated with a greater HR of 10-year mortality (HR 1.14, 95% CI 1.12 to 1.17). Hospitals serving a greater proportion of Black patients are less likely to use CPM, suggestive of disparities in access to CPM at the institutional level. Further research and education are needed to characterize surgeon-specific and institutional practices in patient counseling and shared decision-making that shape disparities in access to CPM.

Disparity Reduction in United States Breast Reconstruction: An Analysis From 2005-2017 Using 3 Nationwide Data Sets.

Following passage of the Women's Health and Cancer Rights Act (WHCRA), a steady rise in breast reconstruction rates was reported; however, a recent update is lacking. This study aimed to evaluate longitudinal trends in breast reconstruction (BR) rates in the U.S. and relevant sociodemographic factors. Mastectomy cases with/without BR from 2005 through 2017 were abstracted from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) Program, and National Cancer Database (NCDB). BR rates were examined using Poisson regression. Multivariable logistic regression analysis of NCDB data was used to identify predictors of reconstruction. Race and insurance distributions were evaluated over time. Of 1,554,381 mastectomy patients, 507,631 (32.7%) received BR. Annual reconstruction rates per 1000 mastectomies increased from 2005 to 2012 (NSQIP: Incidence Rate Ratio (IRR) 1.077; SEER: 1.090; NCDB: 1.092) and stabilized from 2013 to 2017. NCDB data showed that patients who were younger (≤59 years), privately insured, had fewer comorbidities, and underwent contralateral prophylactic mastectomy were more likely to undergo BR (all p<0.001). Over time, the increase in BR rates was higher among Black (252.3%) and Asian (366.4%) patients than White patients (137.3%). BR rates increased more among Medicaid (418.6%) and Medicare (302.8%) patients than privately insured (125.3%) patients. This analysis demonstrates stabilization in immediate BR rates over the last decade; reasons behind this stabilization are likely multifactorial. Disparities based on race and insurance type have decreased, with a more equitable distribution of BR rates.

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

BackgroundThe 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. MethodsRetrospective 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. ResultsA 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. ConclusionsThe 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 messageThis 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.

Construction and Validation of a Nomogram Predicting the Overall Survival Benefit of Unilateral Breast Cancer Patients Undergoing Contralateral Prophylactic Mastectomy

BackgroundCurrently, research on the prognostic factors of unilateral breast cancer (UBC) patients receiving contralateral prophylactic mastectomy (CPM) is limited. This study aimed to construct a new nomogram to predict these patients' overall survival (OS). MethodsIn this retrospective study, 88,477 patients who underwent CPM or unilateral mastectomy (UM) were selected from the Surveillance, Epidemiology, and End Results database. Kaplan-Meier curves and Cox regression analyses were used to determine the difference in the impact of the 2 surgical methods on the prognosis. Multivariate Cox analysis was used to determine the best prognostic variable and construct a nomogram. The concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to evaluate the discrimination capability and clinical effectiveness of the nomogram. ResultsThe prognosis of patients receiving CPM and UM was significantly different. The DCA curves indicated that the nomogram could provide more excellent clinical net benefits for these patients. The NRI and IDI of the nomogram demonstrated that its performance was better than that of the classical tumor-node-metastasis (TNM) staging system. ConclusionThis study developed and validated a practical nomogram to predict the OS of UBC patients undergoing CPM, which provided a beneficial tool for clinical decision-making management.

Choosing contralateral prophylactic mastectomy for unilateral breast cancer in an urban South African breast cancer clinic

Abstract Background: International trends have shown that female patients with unilateral breast cancer are electing bilateral mastectomies as a prophylactic measure. The study aimed to determine the prevalence of unilateral mastectomies (UM) with and without contralateral prophylactic mastectomy (CPM) and to identify whether demographic and pathological characteristics predict the choice of CPM. Methods: A record review of demographic details and pathological results of all female patients undergoing mastectomy for unilateral breast cancer from 2013-2015 was conducted at the Helen Joseph Breast Care Clinic in Johannesburg, South Africa. Results: A total of 299 women who had mastectomies for unilateral breast cancer were included in the study. Of these, 59 had CPM (19.7%). Significantly more White women opted for a CPM than Black women (43.5% vs 10.6%, p♯αμπ;λτ;0.0001). Women who underwent CPM were significantly younger, and there was a trend for higher median breast weight than patients who only underwent UM (p = 0.03 and p = 0.09, respectively). There was no difference between the two groups with regard to patient income status, tumour histology, TNM stage or neoadjuvant chemotherapy. Conclusion: The demographic and histopathological characteristics of breast cancer which influence the choice of CPM in the South African context have some similarities to those in the international literature in that White and younger women more often choose CPM compared to other racial groups. The more advanced stages of breast cancer presentation in our study suggest that public health awareness and screening measures need to be significantly strengthened in South Africa.

Age-Related Incidence and Peak Occurrence of Contralateral Breast Cancer

Young patients with breast cancer have higher risk for developing contralateral breast cancer (CBC) and have epidemiologic characteristics different from those of older patients. To examine the incidence and peak occurrence of CBC according to age at primary breast cancer (PBC) surgery. This cohort study included patients who were diagnosed with and underwent surgery for unilateral nonmetastatic breast cancer at Asan Medical Center, Korea, between January 1, 1999, and December 31, 2013, with follow-up through December 31, 2018. Data were analyzed from December 1, 2021, through April 30, 2023. Patients were divided into 2 groups according to their age at surgery for PBC: younger (≤35 years) vs older (>35 years). The main outcomes were cumulative incidence and hazard rate of CBC in the entire study population and in subgroups divided by cancer subtype, categorized according to hormone receptor (HR) and ERBB2 status. A total of 16 251 female patients with stage 0 to III breast cancer were analyzed; all patients were Korean. The mean (SD) age was 48.61 (10.06) years; 1318 patients (8.11%) were in the younger group, and 14 933 (91.89%) were in the older group. Median follow-up was 107 months (IQR, 79-145 months). Compared with the older group, the younger group had significantly higher incidence of CBC (10-year cumulative incidence, 7.1% vs 2.9%; P < .001) and higher risk (hazard ratio, 2.10; 95% CI, 1.62-2.74) of developing CBC. The hazard rate, which indicates risk for developing CBC at a certain time frame, differed according to the subtype of primary cancer. In patients with the HR+/ERBB2- subtype, the risk increased continuously in both age groups. In patients with the triple negative subtype, the risk increased until approximately 10 years and then decreased in both age groups. Meanwhile, in the HR-/ERBB2+ subtype, risk peaked earlier, especially in the younger group (1.7 years since first surgery in the younger group and 4.8 years in the older group). In this cohort study, patients aged 35 years or younger with breast cancer had a higher risk of developing CBC than older patients. Moreover, young patients with the HR-/ERBB2+ subtype tended to have a shorter interval for developing CBC. These findings might be useful in guiding treatment decisions, such as contralateral prophylactic mastectomy.

Comparing Prognosis for BRCA1, BRCA2, and Non-BRCA Breast Cancer

Background: Germline pathogenic variants (PV) in BRCA1 and BRCA2 genes, which account for 20% of familial breast cancer (BC) cases, are highly penetrant and are associated with Hereditary Breast/Ovarian Cancer Syndrome. Previous studies, mostly including higher numbers of BRCA1 BC patients, yielded conflicting results regarding BRCA1/2 BC outcomes. In the Portuguese population, BRCA2 BC is diagnosed more frequently than BRCA1 BC. We aimed to compare clinicopathological characteristics and prognosis between BC patients with BRCA1 and BRCA2 mutations and a control group without germline PV (BRCA-wt). Furthermore, we explored the frequency and outcomes of risk-reducing surgeries in BRCA-mutated patients. Methods: Prospective follow-up was proposed for patients with a diagnosed BRCA1/2 PV. For this study, a matched control group (by age at diagnosis, by decade, and by stage at diagnosis) included BC patients without germline PV. We compared overall survival (OS) and invasive disease-free survival (iDFS) within the three groups, and the use of risk-reducing surgeries among the BRCA cohort. Results: For a mean follow-up time of 113.0 months, BRCA-wt patients showed longer time to recurrence (p = 0.002) and longer OS (p &lt; 0.001). Among patients with BRCA mutations, no statistical differences were found, although patients with BRCA2 BC had longer iDFS and OS. Uptake of risk-reducing surgeries (contralateral prophylactic mastectomy and salpingo-oophorectomy) were negative predictors of invasive disease and death, respectively. Conclusions: Testing positive for a BRCA PV is associated with a higher risk of relapse and death in patients with BC in the Portuguese population. Risk-reducing mastectomy and salpingo-oophorectomy were associated with lower incidence of relapse and longer median iDFS and OS, respectively.

Contralateral prophylactic mastectomy for unilateral breast cancer in Chinese female population: a retrospective cohort study.

Due to differences in socioeconomic and cultural backgrounds, the characteristics and prognosis of Asian female patients choosing contralateral prophylactic mastectomy (CPM) are likely to be different from Western patients. To fill the research gap of CPM in Asian populations, this study aims to explore the application trend, survival benefits, decision-making factors, and satisfaction of CPM based on the Chinese patients undergoing CPM. The 0-III stage unilateral breast cancer (UBC) patients who received breast surgery in the Chinese PLA General Hospital from 2005 to 2017 were selected. The surgical procedures included simple mastectomy (SM), nipple-sparing mastectomy (NSM), breast conserving surgery (BCS), and CPM. Cox proportional regression analyses and Kaplan-Meier (KM) curve were performed to compare the overall survival (OS) and disease-free survival (DFS) rates between CPM group and unilateral mastectomy (UM) group. Proportional propensity score matching (PSM) with a 1:1 ratio was used to match the two groups and secondary survival analysis was performed. Logistic regression models were used to test predictive factors related to patients' CPM surgical decision-making. Four thousand two hundred and seventy-six patients were included in the study, with 73 patients receiving CPM, 3,567 receiving SM, 151 receiving NSM, and 485 receiving BCS. CPM surgery was first used in 2007, with a peak application rate of 3.02% in 2016. Three thousand seven hundred and ninety-one patients were included in the survival analysis, with a median follow-up time of 66.60 months. Compared to UM patients, neither the KM survival curve nor Cox regression hazard analyses of CPM showed better OS (P=0.963; P=0.834). After PSM, CPM also did not exhibit significant survival benefits in OS (P=0.335) and DFS (P=0.409). The logistic regression analyses showed that NSM surgery and lower tumor-node-metastasis (TNM) stage were independent factors to promote the CPM decision-making of patients. The CPM group showed high overall satisfaction (84.9%) and relatively low appearance satisfaction (69.9%). CPM was practiced for the first time since 2007 in our hospital. CPM does not provide any OS and DFS benefits compared to UM and the appearance satisfaction procedure was relatively low. Therefore, clinicians should fully communicate with patients before surgery and be more cautious in giving CPM recommendations.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy

Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy. A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected. In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients. There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Patient-driven decisions and perceptions of the ‘safest possible choice’: insights from patient-provider conversations about how some breast cancer patients choose contralateral prophylactic mastectomy

Objective Observe patient-clinician communication to gain insight about the reasons underlying the choice of patients with unilateral breast cancer to undergo contralateral prophylactic mastectomy (CPM), despite lack of survival benefit, risk of harms, and cautions expressed by surgical guidelines and clinicians. Methods & Measures WORDS is a prospective study that explored patient-clinician communication and patient decision making. Participants recorded clinical visits through a downloadable mobile application. We analyzed 44 recordings from 22 patients: 9 who chose CPM, 8 who considered CPM but decided against it, and 5 who never considered CPM. We used abductive analysis combined with constructivist grounded theory methods. Results Decisions to undergo CPM are patient-driven and motivated by perceptions that CPM is the most aggressive, and therefore safest, treatment option available. These decisions are shaped not primarily by the content of conversations with clinicians, but by the history of cancer in patients’ families, their own first-hand experiences with cancers among loved ones, fear for their children, and anxiety about cancer recurrence. Conclusion The perception that CPM is the safest, most aggressive option strongly influences patients, despite scientific evidence to the contrary. Future efforts to address high CPM rates should focus on patient-driven decision making and cancer-related fears.