Comparing Therapeutic versus Prophylactic Nipple-Sparing Mastectomy: Does Indication Inform Oncologic and Reconstructive Outcomes?

Comparing Therapeutic versus Prophylactic Nipple-Sparing Mastectomy: Does Indication Inform Oncologic and Reconstructive Outcomes?

by Frey, Jordan D.; Salibian, Ara A.; Karp, Nolan S.; Choi, Mihye  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 306–315

Background: Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. Methods: Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. Results: A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). Conclusions: Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Contralateral Prophylactic Mastectomy

Contralateral Prophylactic Mastectomy

Ramaswami R
New England Journal of Medicine, Volume 377, Issue 13, Page 1288-1291, September 2017.

CASE VIGNETTE
A Woman Considering Contralateral Prophylactic Mastectomy

A 51-year-old woman who has recently received a diagnosis of breast cancer, and she comes to you to seek your opinion about her surgical options. Three weeks earlier, she had undergone mammography and magnetic resonance imaging to evaluate a mass in the left breast. She has been told that she has a 3-cm triple-negative (i.e., negative for estrogen and progesterone receptors and for overexpression of human epidermal growth factor receptor type 2 [HER2]) invasive ductal carcinoma of the left breast. The breast cancer is at clinical stage IIA or T2N0M0 .......

An Analysis of the Decisions Made for Contralateral Prophylactic Mastectomy and Breast Reconstruction

An Analysis of the Decisions Made for Contralateral Prophylactic Mastectomy and Breast Reconstruction
Plastic and Reconstructive Surgery
Buchanan PJ et al

Background: Little is known about the role breast reconstruction plays in decisions made for contralateral prophylactic mastectomy. This study explores factors critical to patient medical decision-making for contralateral prophylactic mastectomy and reconstruction among women with early stage, unilateral breast cancer. Methods: A mixed methods approach was used to gain an understanding of patients’ choices and experiences. Patients with stage 0 to III unilateral breast cancer who underwent reconstruction were recruited, and semistructured interviews were conducted. Patient-reported outcomes were evaluated using the Concerns About Recurrence Scale and the BREAST-Q. Results: Thirty patients were enrolled; 13 (43 percent) underwent unilateral mastectomy and 17 (57 percent) underwent contralateral prophylactic mastectomy. Three broad categories emerged from patient interviews: medical decision-making, quality of life after mastectomy, and breast reconstruction expectations. Patients who chose contralateral prophylactic mastectomy made the decision for mastectomy based primarily on worry about recurrence. Quality of life after mastectomy was characterized by relief of worry, especially in patients who chose contralateral prophylactic mastectomy [n = 14 (82.4 percent)]. Patients’ desires for symmetry, although not the primary reason for contralateral prophylactic mastectomy, played a role in supporting decisions made. Levels of worry after treatment were similar in both groups (72.7 percent). Patients with contralateral prophylactic mastectomy had higher mean scores for satisfaction with breast (82.4 versus 70.6) and satisfaction with outcome (89.9 versus 75.2). Conclusions: The choice for contralateral prophylactic mastectomy is greatly influenced by fear of recurrence, with desires for symmetry playing a secondary role in decisions made. 

Decision making, psychological wellbeing and psychosocial outcomes for high risk women who choose to undergo bilateral prophylactic mastectomy – A review of the literature

Decision making, psychologicalwellbeing and psychosocial outcomes for high risk women who choose to undergobilateral prophylactic mastectomy – A review of the literature

The Breast August 2016 Volume 28, Pages 130–135

Glassey R, Ives A, Saunders C, Musiello T

A bilateral prophylactic, or preventative, mastectomy (BPM) for women at high risk of developing breast cancer (BC) can reduce their risk of developing the disease by up to 90% (relative risk reduction). An increasing number of women, including young women, are taking up this option. However, there is a dearth of information for younger women (under 40 years) choosing preventative mastectomy. In fact, no studies to date have specifically focused on younger women's experiences of a BPM and investigated their informational needs.

Cost-effectiveness of contralateral prophylactic mastectomy

Cost-effectiveness of contralateral prophylactic mastectomy versus routine surveillance in patients with unilateral breast cancer. Journal of Clinical Oncology 2011; Vol. 29(22), p. 2993-3000.

Zendejas, B., et al.

http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?ID=22011001483

The objective was to evaluate the cost-effectiveness of contralateral prophylactic mastectomy versus routine surveillance in patients with unilateral breast cancer. The authors concluded that contralateral mastectomy was cost-effective, compared with surveillance, for patients younger than 70 years.

Annals of Surgery March 2010 Vol 251 Iss 3

p488-492
Prophylactic Mastectomy in BRCA1 and BRCA2 Mutation Carriers: Very Low Risk for Subsequent Breast Cancer
Reinoutje Kaas, MD, PhD; Senno Verhoef, MD, PhD; Jelle Wesseling et al

p493-498
Nipple Areola Skin-Sparing Mastectomy With Immediate Transverse Rectus Abdominis Musculocutaneous Flap Reconstruction is an Oncologically Safe Procedure: A Single Center Study
Hee Jeong Kim, MD, PhD; Eun Hwa Park, MD; Woo Sung Lim, MD; Jin Young Seo et al

p499-505
Circulating microRNAs as Novel Minimally Invasive Biomarkers for Breast Cancer
Helen M. Heneghan, MD; Nicola Miller, PhD; Aoife J. Lowery, MD; Karl J. Sweeney et al

The Breast Journal Vol 15 Iss 1 2009

S1-S1
Breast Cancer Risk Assessment and Follow-up Management: Is There a Magic Marker to Identify High Risk Individuals?
Shahla Masood
AbstractPublished Online: 22 Sep 2009

ORIGINAL ARTICLES
S2-S10
Genetic Counseling and the Advanced Practice Oncology Nursing Role in a Hereditary Cancer Prevention Clinic: Hereditary Breast Cancer Focus (Part I)
Carrie L. Snyder, Jane F. Lynch, Henry T. Lynch
AbstractPublished Online: 22 Sep 2009
S11-S19
Genetic Counseling and the Advanced Practice Oncology Nursing Role in a Hereditary Cancer Prevention Clinic: Hereditary Breast Cancer Focus (Part II)
Henry T. Lynch, Carrie L. Snyder, Jane F. Lynch
AbstractPublished Online: 22 Sep 2009
S20-S24
Family Information Service Participation Increases the Rates of Mutation Testing Among Members of Families with BRCA1/2 Mutations
Henry T. Lynch, Carrie L. Snyder, Jane F. Lynch, Sumedha Ghate, Steven A. Narod, Gordon Gong
AbstractPublished Online: 22 Sep 2009
S25-S32
Controversies in Communication of Genetic Risk for Hereditary Breast Cancer
Amy MacKenzie, Linda Patrick-Miller, Angela R. Bradbury
AbstractPublished Online: 22 Sep 2009
S33-S38
Establishing a Family Risk Assessment Clinic for Breast Cancer
Jurgen Mulsow, James Lee, Cathriona Dempsey, Jane Rothwell, James G. Geraghty
AbstractPublished Online: 22 Sep 2009
S39-S45
Assessing Breast Cancer Risk and Providing Treatment Recommendations: Immediate Impact of an Educational Session
Sheryl G.A. Gabram, Teri Dougherty, Kathy S. Albain, Kimberly Klein, Patricia Mumby, Kit Lee, Kathy Yao, Bhuma Krishnamachari, Catheryn J. Salibay, Mary Jo Lund
AbstractPublished Online: 22 Sep 2009
S46-S55
Electronic Health Records and the Management of Women at High Risk of Hereditary Breast and Ovarian Cancer
Brian Drohan, Elissa M. Ozanne, Kevin S. Hughes
AbstractPublished Online: 22 Sep 2009
S56-S62
Influence of Race/Ethnicity on Genetic Counseling and Testing for Hereditary Breast and Ovarian Cancer
Andrea D. Forman, Michael J. Hall
AbstractPublished Online: 22 Sep 2009
S63-S71
Risk of Breast Cancer Among French-Canadian Women, Noncarriers of More Frequent BRCA1/2 Mutations and Consumption of Total Energy, Coffee, and Alcohol
Vishnee Bissonauth, Bryna Shatenstein, Eve Fafard, Christine Maugard, André Robidoux, Steven Narod, Parviz Ghadirian
AbstractPublished Online: 22 Sep 2009
S72-S75
Breast Cancer Risk Assessments Comparing Gail and CARE Models in African-American Women
Lucile L. Adams-Campbell, Kepher H. Makambi, Wayne A.I. Frederick, Melvin Gaskins, Robert L. DeWitty, Worta McCaskill-Stevens
AbstractPublished Online: 22 Sep 2009
S76-S80
Targeted Tailored Management of the Breast Cancer Patient at Risk for Harboring a Germline Mutation—Current Trends Affecting the Selection of Patients Considering Surgical Prophylaxis for Breast Cancer
Edibaldo Silva
AbstractPublished Online: 22 Sep 2009
S81-S89
Breast Reconstruction after Bilateral Prophylactic Mastectomy in Women at High Risk for Breast Cancer
Liron Eldor, Aldona Spiegel
AbstractPublished Online: 22 Sep 2009
S90-S94
Breast Ductoscopy and the Evolution of the Intra-Ductal Approach to Breast Cancer
William C. Dooley
AbstractPublished Online: 22 Sep 2009

British Journal of Surgery Vol 96 Iss 7 2009

Corespondence

p. 824
Prophylactic mastectomy and the timing of breast reconstruction (Br J Surg 2009; 96: 1-2)
Z. E. Winters
AbstractPublished Online: 15 Jun 2009

p. 824-825
Authors' reply: Prophylactic mastectomy and the timing of breast reconstruction (Br J Surg 2009; 96: 1-2)
B. J. Mehrara, M. Morrow
AbstractPublished Online: 15 Jun 2009

Link to journal
Spear, Scott L.; Schwarz, Karl A.; Venturi, Mark L. ; Barbosa, Todd ; Al-Attar, Ali
Prophylactic Mastectomy and Reconstruction: Clinical Outcomes and Patient Satisfaction
Plastic & Reconstructive Surgery. 122(1):1-9, July 2008.
Abstract
Background: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction.
Methods: A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons.
Results: There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again.
Conclusions: Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.