Mastectomy In Young Women Research Articles

Contralateral Prophylactic Mastectomy in Young Women With Breast Cancer: A Population-Based Analysis of Predictive Factors and Clinical Impact

Contralateral prophylactic mastectomy (cpm) has been increasingly common among women with unilateral invasive breast cancer (ibca) even though the data that support it are limited. Using a population-based cohort, the objectives of the present study were to describe factors predictive of cpm in young women (≤35 years) with ibca and to evaluate the impact of the procedure on mortality. All women diagnosed during 1994-2003 and treated with cpm were identified from the Ontario Cancer Registry. Logistic regression was used to identify patient and tumour factors associated with the use of cpm. Multivariate analyses were used to assess the effect of cpm on recurrence and mortality. Of 614 women identified, 81 underwent cpm (13.2%). On multivariable analysis, factors associated with cpm included negative lymph node status, negative estrogen receptor status, and initial breast-conserving surgery with re-excision. At follow-up, breast cancer-specific mortality was similar for women who did and did not undergo cpm. Use of cpm in young women with ibca (compared with non-use) was not associated improved breast cancer-specific mortality. Factors found to be predictive of cpm were negative lymph node status, negative estrogen receptor status, and initial breast-conserving surgery followed by re-excision.

Breast-conserving surgery versus mastectomy in young women with breast cancer in Asian settings.

BackgroundMastectomy rates among women with early breast cancer in Asia have traditionally been high. This study assessed trends in the surgical management of young women with early‐stage breast cancer in Asian settings. Survival in women treated with breast‐conserving surgery (BCS; lumpectomy with adjuvant radiotherapy) and those undergoing mastectomy was compared.MethodsYoung women (aged less than 50 years) newly diagnosed with stage I or II (T1–2 N0–1 M0) breast cancer in four hospitals in Malaysia, Singapore and Hong Kong in 1990–2012 were included. Overall survival (OS) was compared for patients treated by BCS and those who had a mastectomy. Propensity score analysis was used to account for differences in demographic, tumour and treatment characteristics between the groups.ResultsSome 63·5 per cent of 3536 women underwent mastectomy. Over a 15‐year period, only a modest increase in rates of BCS was observed. Although BCS was significantly associated with favourable prognostic features, OS was not significantly different for BCS and mastectomy; the 5‐year OS rate was 94·9 (95 per cent c.i. 93·5 to 96·3) and 92·9 (91·7 to 94·1) per cent respectively. Inferences remained unchanged following propensity score analysis (hazard ratio for BCS versus mastectomy: 0·81, 95 per cent c.i. 0·64 to 1·03).ConclusionThe prevalence of young women with breast cancer treated by mastectomy remains high in Asian countries. Patients treated with BCS appear to survive as well as those undergoing mastectomy.

Survival following breast-conserving therapy is equal to that following mastectomy in young women with early-stage invasive lobular carcinoma

BackgroundPrevious observational studies reported the superior survival of patients with early-stage breast cancer who underwent breast-conserving therapy (BCT, lumpectomy plus postsurgical radiation) compared to that of those who underwent mastectomy. Invasive lobular carcinoma (ILC) is not the same disease as invasive ductal carcinoma (IDC) as it has distinct biologic features and thus requires unique consideration and research. MethodsWe selected women (≤50 years of age) from the Surveillance, Epidemiology, and End Results (SEER) database diagnosed with stage T1–2, N0–1, M0 primary breast cancer with invasive lobular features between 1998 and 2011, that were treated with either BCT or mastectomy with and without radiation. We assessed survival proportions using the Kaplan-Meier method and hazard ratios using Cox proportional hazards models. Breast cancer-specific survival (BCSS) served as the primary endpoint. ResultsA total of 3393 eligible young ILC patients were identified, 1391 (41%) of which underwent lumpectomy followed by radiation. The 10-year BCSS rates for patients who received BCT, mastectomy alone and mastectomy with radiation were 95.7%, 94.2% and 89.3%, respectively. Multivariate analysis showed that BCSS was not improved in patients assigned to mastectomy alone group (HR = 0.86; 95% CI 0.57–1.28) or mastectomy with postsurgical radiation group (HR = 0.97; 95% CI 0.58–1.62) compared to that in those who underwent BCT. The results did not changed when evaluating the 1998–2004 and 2005–2011 time periods separately. ConclusionNone of the treatment demonstrated an absolute superiority in young women with early-stage ILC. Future studies with more detailed analyses of the confounding factors are worthwhile.

Abstract PD6-02: Local recurrence in young women with invasive breast cancer; the prospective study of outcomes in sporadic and hereditary breast cancer (POSH)

Abstract Aim To evaluate the surgical and clinical factors affecting local recurrence and other outcomes in young breast cancer patients using the POSH study. Background POSH (MREC:00/06/69) is a prospective cohort study of 3024 women aged 18-40 with breast cancer. Randomized controlled trials suggest equivalent survival between mastectomy and breast conserving surgery (BCS); however, very few young patients were included in these analyses. Emerging data also suggests a possible survival advantage for mastectomy in gene mutation carriers, and young age may be a predictor of higher rates of local recurrence. Methods Summary statistics were used to describe the cohort by surgical type (mastectomy or BCS). Study endpoints were in-breast ipsilateral local-recurrence interval, distant disease-free interval and overall survival. Cumulative hazard and Kaplan-Meier plots were used to describe survival data. Univariable and multivariable analyses were carried out using Cox proportional hazards models and flexible parametric survival (FPS) models (for any models with time-varying covariates). Results Of 2882 patients analysed, 1464 underwent mastectomy, 1395 BCS; and 23 had lymph node surgery only. Patients undergoing mastectomy had significantly larger tumours and higher proportions of positive Family History, positive estrogen receptor (ER+), progesterone receptor (PR+) and/or human epidermal growth factor 2 (HER2+) tumours. Local events only accounted for 15% of recurrences. Local recurrence varied over time by surgical type; local recurrence rate was similar at 18 months but higher for BCS compared to mastectomy at 5- and 10-years (18-months: 1.0% vs 1.0%, FPS-HR[95%CI]=1.43[0.89,2.32], p=0.348; 5-years: 5.3% vs 2.6%, FPS-HR[CI]=3.39[2.03,5.66], p<0.001; and 10-years: 11.7% vs 4.9%, FPS-HR[CI]=5.27[2.43,11.43], p<0.001, respectively). Similar results were found in the adjusted model and when restricting the analyses to patients with smaller tumours. Conversely, distant-metastases and death events were significantly lower for BCS but not after adjusting for prognostic factors. Chest-wall radiotherapy following mastectomy was associated with improved local recurrence interval (HR[CI]=0.46[0.24,0.86],p=0.015). Positive surgical margins, and the development of a local event, predicted for reduced distant disease free interval (HR[CI]=0.50[0.35,0.71],p<0.001; and 10-year FPS-HR[CI]=0.29[0.14,0.62],p=0.001, respectively). Conclusions In the short term, there is no difference in local recurrence between BCS and mastectomy in young women. Longer term, local recurrence is higher in BCS, but there is no difference in survival between surgical groups after adjusting for known prognostic factors. Surgical extent appears to be less important for distant relapse or death from breast cancer than completeness of excision or, where appropriate, chest-wall radiotherapy. Acknowledgements Data collection/analysis funded by CRUK (grants:A7572,A11699,C1275/A15956). Sponsored by UHS NHS Foundation Trust. Citation Format: Maishman T, Cutress RI, Hernandez A, Gerty S, Copson ER, Durcan L, Eccles DM. Local recurrence in young women with invasive breast cancer; the prospective study of outcomes in sporadic and hereditary breast cancer (POSH) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD6-02.

Local Therapy Decision-Making and Contralateral Prophylactic Mastectomy in Young Women with Early-Stage Breast Cancer.

Rates of contralateral prophylactic mastectomy (CPM) have increased in the United States, with younger women with breast cancer the most likely to have CPM. As part of an ongoing cohort study of young women diagnosed with breast cancer at age ≤40 years, we conducted multinomial logistic regression of data from 560 women with unilateral Stage I-III disease to identify factors associated with: (1) CPM versus unilateral mastectomy (UM); (2) CPM versus breast-conserving surgery (BCS). Median age at diagnosis was 37 years; 66 % of women indicated that their doctor said that BCS was an option or was recommended. Of all women, 42.9 % had CPM, 26.8 % UM, and 30.4 % BCS. Among women who said the surgical decision was patient-driven, 59.9 % had CPM, 22.8 % BCS, and 17.3 % UM. Clinical characteristics associated with CPM versus BCS included HER2 positivity, nodal involvement, larger tumor size, lower BMI, parity, and testing positive for a BRCA mutation. Emotional and decisional factors associated with CPM versus UM and BCS included anxiety, less fear of recurrence, and reporting a patient-driven decision. Women who reported a physician-driven decision were less likely to have had CPM than both of the other surgeries, whereas higher confidence with the decision was associated with having CPM versus BCS. Many young women with early-stage breast cancer are choosing CPM. The association between CPM and emotional and decisional factors suggest that improved communication together with better psychosocial support may improve the decision-making process.

Abstract P2-13-07: Prophylactic mastectomy in young women with breast cancer

Abstract Background: In recent years women with unilateral breast cancer (BC) have been increasingly requesting contralateral or bilateral prophylactic mastectomy (PM) despite only requiring unilateral mastectomy (M) or lumpectomy (L) respectively. This trend has been observed even in women at low risk for contralateral BC, particularly among younger women. Objective: Determine the rates of ‘unexplained’ PM (UPM) and factors associated with this choice, among a prospective cohort of newly diagnosed young women with BC at our centre. Methods: We reviewed the records of all patients diagnosed with BC at age ≤ 40 years from Feb ‘08 to Sept ’13 at Sunnybrook who consented to have their clinical data entered in a prospective research database. Psychosocial data - HADS [Hospital Anxiety and Depression Scale] and IES [Impact of Event Scale] - were prospectively collected from all consenting women at baseline and at completion of active treatment. Among the 149 patients treated with curative intent, 43 received unilateral M, 59 L and 47 contralateral or bilateral PM. These groups were compared with respect to demographics, risk factors, use of pre-operative MRI, pathology, treatment and surgeon gender. Differences in variables between the groups were analyzed using analysis of variance for continuous variables and chi-square test for categorical variables. Results: The mean age of all patients was 35 years old (21-40 range). Among the 47 patients who had PM, the first surgery was L for 15 (32%), unilateral M for 27 (57%) and bilateral M for 5 (11%). Twenty-four (51%) fulfilled high risk criteria (19 BRCA mutation, 4 strong family history, 1 chest radiation) and 2 (4%) had suspicious findings in the contralateral breast. The other twenty-one patients (45%) underwent UPM for "peace of mind" alone. Thirty-three (33%) of UPM patients had T3-4 tumors. There were no statistically significant differences between the UPM group and the combined M plus L groups, except for more multicentric/ multifocal disease in the UPM groups (43% vs 9% p≤0.0001). Discussion: Fourteen percent of young women at our centre, a 1/3 with a relatively poor prognosis had UPM. Data correlating surgical choice with baseline and follow-up psychological variables will be presented. There appears to be a need for an educational/psychological intervention at the time of BC diagnosis for non-high-risk women contemplating preventive breast surgery to ensure that such a choice is truly informed. Citation Format: Cristiane Metran Nascente, Frances Wright, Christel Helwig, Nim Li, Rodica Mandel, Alex Kiss, Ellen Warner. Prophylactic mastectomy in young women with breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-07.

Contralateral mastectomy in young women with breast cancer: A population-based analysis of predictive factors and clinical impact.

82 Background: Contralateral mastectomy (CM) has recently been shown to be associated with survival benefit in women with breast cancer. The objectives of the present study were to describe factors predictive of CM in young women (≤35 years old) with invasive breast cancer and evaluate its impact on survival, in a large population based cohort. Methods: All women diagnosed with invasive breast cancer aged ≤35 from 1994 – 2003 treated with mastectomy were identified from the Ontario Cancer Registry. Patient demographics, complete tumour and treatment characteristics were abstracted from primary chart review. Cox proportional hazard regression was performed to assess factors associated with performance of CM and its effect on recurrence and overall survival, performance of CM was modeled as a time varying co-variate. The models were controlled for known predictors including age, tumor size, nodal status, ER/PR, LVI, histologic grade, systemic therapy and adjuvant radiation. Results: There were 628 women identified. Of these, 101 underwent a CM (16.1%). On multivariable analysis, factors predictive of CM were negative lymph node status (HR: 1.74, 95% CI [1.052-2.872]; p-value = 0.031) and negative estrogen receptor status (HR: 2.7, 95% CI [1.314-5.736]; p-value = 0.007). After a median follow up of 11 years, no significant survival benefit was observed in women undergoing CM compared to those who did not (HR: 0.95, 95% CI [0.61-1.46], p-value = 0.80). Conclusions: Performance of CM in young women with invasive breast cancer did not result in a significant survival benefit, compared to those without CM. Factors found to be predictive of performance of CM negative lymph node status and negative estrogen receptor status. Further studies are needed to determine if a subset of young women might benefit from CM.

Abstract P2-18-02: Factors associated with contralateral prophylactic mastectomy in young women with breast cancer

Abstract Background: While younger age at diagnosis has consistently been identified as a predictor of contralateral prophylactic mastectomy (CPM), little is known about how clinical, decisional, and psychosocial factors are related to the decision to undergo CPM in young women with breast cancer. Methods: As part of an ongoing, multi-center cohort study of young women diagnosed with breast cancer at age 40 or younger, we identified 428 women with unilateral Stage I-III disease. Participants were asked to complete surveys by mail that included questions about decision-making and treatments. Tumor characteristics were ascertained via medical record review. Multinomial logistic regression was used to identify predictors of: 1) CPM vs. unilateral mastectomy (UM); 2) CPM vs. breast conserving surgery (BCS). Independent variables with a p-value ≤ 0.15 in bi-variate analyses were included in the final multivariable model. Results: 41% of women had CPM, 29% had UM and 31% had BCS. Median age at diagnosis was 37 (range: 17-40). Most women had stage I or II disease (87%), and estrogen receptor (ER) positive tumors (69%); approximately 14% were carriers of a BRCA 1 or 2 mutation. In the multivariable analysis (Table 1), having a cancer-predisposing mutation, having at least one child, anxiety as measured by the Hospital Anxiety and Depression Scale (HADS), and patient-driven decision making were all associated with a greater likelihood of undergoing CPM, while women who reported their physician made the final decision about surgery were less likely to undergo CPM, compared to both UM and BCS. Additional factors significantly associated with undergoing CPM vs. BCS included nodal involvement, Her2 positivity, and lower BMI. Race/ethnicity, marital status, tumor size, tumor grade, depression (as measured by the HADS), fear of recurrence, and having a first-degree relative with breast or ovarian cancer were not associated with undergoing CPM. Conclusion: Many young women with early stage breast cancer are choosing to undergo CPM. Our findings point to the need for improved communication with patients regarding surgical choices as well as better management of anxiety surrounding diagnosis. Interventions aimed at enhancing risk communication and encouraging shared patient-physician decision-making might be beneficial in this setting. Table 1. Factors associated with: 1) CPM vs. UM; 2) CPM vs. BCS CPM vs. UMCPM vs. BCS OR (95% CI)OR (95% CI)Age at diagnosis0.92 (0.86-1.00)0.97 (0.90-1.04)Mutation positive3.83 (1.60-9.15)14.51 (5.02-41.92)Any nodal involvement0.79 (0.45-1.38)1.93 (1.05-3.55)Her2 positivity0.71 (0.40-1.26)2.24 (1.18-4.25)Having ≥ 1 child2.08 (1.04-4.14)3.25 (1.63-6.48)BMI0.98 (0.92-1.03)0.92 (0.87-0.97)Anxiety1.93 (1.05-3.56)2.31 (1.22-4.35)Decisional involvement (ref = shared) Mainly patient's decision3.47 (1.99-6.06)3.71 (2.09-6.58)Mainly doctor's decision0.14 (0.03-0.63)0.16 (0.03-0.77) Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-02.

Comparison of Recurrence and Survival Rates after Breast-Conserving Therapy and Mastectomy in Young Women with Breast Cancer

Multiple randomized trials have demonstrated that breast-conserving therapy with partial mastectomy and radiotherapy provides survival equivalent to that seen with mastectomy for patients with early-stage breast cancer. Breast-conserving therapy has been associated with better quality of life relative to mastectomy and has become the standard of care for patients with early-stage breast cancer. Young age has been identified as a risk factor for recurrence and death from breast cancer. Some studies have suggested that young women (less than 35 or 40 years of age) have inferior outcomes with breast-conserving therapy, implying that such women may be better served by mastectomy. On review of the available literature, there is no definitive evidence that mastectomy provides a consistent, unequivocal recurrence-free or overall survival benefit over breast-conserving therapy. However, available meta-analyses have not compared outcomes in young women specifically, and such analyses should be performed. In the interim, breast-conserving therapy is not contraindicated in young women (less than 40 years of age) and can be used cautiously; however, such women should be advised of the lack of unequivocal data proving that survival is equivalent to that with mastectomy in their age group.

Contralateral risk-reducing mastectomy in young women

Contralateral risk-reducing mastectomy consists in the surgical removal of the contralateral breast to reduce the risk of breast cancer there [1]. Patients with unilateral primary breast cancer have an increased risk of developing a contralateral breast cancer [2]. In a large-scale study, Quan et al. [3] evaluated the incidence, stage and outcomes of women with contralateral synchronous (defined as tumors diagnosed within 12 months of the initial diagnosis) and metachronous (tumors diagnosed beyond 12 months after the initial diagnosis) breast cancer over a 9-year study period. In the 28,787 cases of breast cancer identified, the mean annual incidence of contralateral breast cancer was 0.1%, while the cumulative incidence of contralateral synchronous cancer was 2.1%, and the cumulative incidence of metachronous cancer was 1.2%. Using the Surveillance, Epidemiology and End Results database (SEER), Gao et al. [4] found that the 5-, 10-, 15-, and 20-year actuarial incidence of developing contralateral breast cancer was 3, 6, 9 and 12%, respectively. The average incidence of contralateral breast cancer per year of follow-up per patient was estimated at 0.6%. Based on these, and other retrospective studies, the incidence rate of contralateral breast cancer in breast cancer patients has been estimated to range from approximately 0.5 to 1.8% per year. Benefits of contralateral risk-reducing mastectomy

Factors contributing to improved local control after mastectomy in patients with breast cancer aged 40 years or younger

Long-term local control rates were studied in a series of 659 patients with invasive breast cancer aged 40 years or younger, who underwent mastectomy in general hospitals in the southern part of the Netherlands between 1988 and 2005. During a median follow-up time of 6.0 years, 34 patients developed a local recurrence in the chest wall without previous or simultaneous evidence of distant disease. The 5- and 10-year actuarial local recurrence rates for the total group were 5.6% (95% confidence interval [95% CI], 3.5–7.7%) and 7.3% (95% CI, 4.7–9.9%), respectively. A multivariate analysis showed that patients receiving radiotherapy (hazards ratio [HR], 0.29; 95% CI, 0.10–0.96) or adjuvant systemic treatment (HR 0.23; 95% CI, 0.08–0.65) had a significantly lower risk of local recurrence. It is concluded that excellent local control rates can be obtained with mastectomy in young women with breast cancer, especially in those who receive adjuvant systemic treatment and/or radiotherapy.

Breast Reconstruction after Mastectomy in Young Women

Young women with breast cancer differ from older women in a number of ways that may affect their experience with breast reconstruction after mastectomy. Parenting, work, or recreational activities may influence a young woman's decisions about whether or not to have reconstruction, timing of reconstruction, and type of reconstruction. Young women with breast cancer are known to experience greater psychological morbidity and poorer quality of life than older women. A young woman's breast anatomy and physiology and overall medical condition generally allow more reconstructive options. Young women can often tolerate autologous reconstruction well, and more young women are expressing interest in perforator-based free tissue transfer to reduce donor site morbidity. Although the reconstructive issues are different for younger women, outcomes of breast reconstruction appear to be the same for women of all ages.

The value of adjuvant treatment in young women with breast cancer.

The postoperative management of breast cancer is an ever-changing field. Young patients, in particular, have attracted recent interest as it has become apparent that age alone is a poor prognostic indicator for breast cancer. Adjuvant therapies indisputably delay breast cancer recurrence and save lives, and should be considered for all young patients. Chemotherapy is increasingly being considered appropriate for all women under the age of 35 years, regardless of other risk factors, but poses the particularly difficult problem of infertility for these young women. As the additional benefits of anthracyclines and taxanes in the adjuvant setting become clear, chemotherapy regimens are also becoming increasingly intensive and the risk of myocardial damage and leukaemia should not be ignored. The benefits of chemotherapy need to be weighed against the possible dangers, and therapy should be individualised according to cancer pathology and patient circumstance. Tamoxifen should be given for 5 years to all women whose cancer is estrogen receptor positive, regardless of whether the patient has received chemotherapy. If chemotherapy is not given, the addition of luteinising hormone-releasing hormone (LHRH) agonists to tamoxifen in patients with estrogen receptor positive breast cancers appears to be beneficial. The addition of LHRH agonists to chemotherapy and tamoxifen is currently being evaluated in randomised trials. Radiotherapy should be given after breast conservation surgery, and should include the axilla if nodes are involved and the axilla has not been surgically cleared. Chest wall radiotherapy should be considered following mastectomy in young women considered at high risk of local recurrence, but the long-term morbidity and mortality of local radiation therapy, which is increased in young women, needs to be considered.