WASHINGTON—A new computer modeling study by University of Minnesota researchers has found that contralateral prophylactic mastectomy in women with early-stage breast cancer who do not have BRCA1 or BRCA2 mutations does not significantly increase life expectancy. The study was presented here at the American College of Surgeons Clinical Congress.
Speaking at a media briefing, Todd M. Tuttle, MD, MS, Chief of Surgical Oncology, noted that there has been a lot of news about double mastectomies in recent years, fueled particularly by the cases of celebrities such as actress Angelina Jolie. The result, though, is that women who (unlike Jolie) lack BRCA genetic mutations have been requesting double mastectomies when cancer is detected in one breast.
“This has primarily been a patient-driven phenomenon,” Tuttle noted. And in fact, the rate of contralateral prophylactic mastectomy has increased by 150 percent from 1988 to 2003 and continues to rise, said another coauthor, Pamela R. Portschy, MD, a surgery resident.
The study used a Markov analytic computer model to compare two groups of women with stage I or II breast cancer without a BRCA mutation: those who underwent a contralateral prophylactic mastectomy, and those who had surgery only on the diseased breast.
The analytical model pooled data on several hundred thousand women age 40 to 60 from two main sources: the Early Breast Cancer Trialists' Collaborative Group; and the NCI's Surveillance, Epidemiology, and End Results program, to examine the risk of developing or dying from contralateral breast cancer and dying from a primary breast cancer and the resulting reduction in contralateral breast cancer due to contralateral prophylactic mastectomy.
The gain in life expectancy from contralateral prophylactic mastectomy ranged from 1.4 to 6.3 months for women with stage I breast cancer and from less than a month to 3.7 months for those with stage II depending on age and estrogen receptor (ER) status.
The absolute 20-year survival differences were less than one percent among all age, ER status, and cancer-stage groups. Among the different groups, contralateral prophylactic mastectomy was more beneficial for 40-year-old, stage I, and ER-negative breast cancer patients, Tuttle reported.
Asked by OT if he thinks the rising trend of double mastectomies is driven at least partially by fear, he said yes, noting that at the time of diagnosis, a breast cancer patient may be so fearful that she just wants to have both breasts surgically removed. In addition, “a patient like Angelina Jolie had a long time to decide what to do—she did not have breast cancer.” In contrast, newly diagnosed patients often have misperceptions about their risk of dying from a new cancer in the opposite breast, when what is more likely to be fatal is metastatic spread from the initial breast cancer.
In fact, he said, women with early-stage breast cancer who lack a BRCA mutation frequently equate their risk of developing contralateral breast cancer to be 30 percent or higher—about the same risk as that for women who have a BRCA mutation. But in reality that risk for early-stage patients who lack a BRCA mutation is only about four to eight percent at 10 years, Tuttle said.
He said that in addition to fear upon diagnosis as a motivation and overestimating the life-saving benefit of contralateral prophylactic mastectomy, women know that mastectomy and breast reconstruction have improved, and they also have an increased awareness of genetic risk factors.
Tuttle and Portschy both said that they hope the study results will help surgeons and their patients make informed, data-based decisions, especially when it comes to the survival benefit of contralateral prophylactic mastectomy, and the hope is that the trend in the U.S. for double mastectomy can be reversed.
Tuttle pointed out that a woman who chooses contralateral prophylactic mastectomy risks the possibility of wound infections, increased discomfort, a longer recovery, and possible complications and further procedures down the road.
Asked by session moderator Elizabeth A. Middendorf, MD, PhD, during the formal presentation of the study data how the results might change how patients are counseled, Portschy replied, “This helps us give accurate information to our patients so they can make the best decisions for themselves.”
Middendorf, Assistant Professor in the Department of Surgical Oncology at the University of Texas MD Anderson Cancer Center, agreed, saying that the work would also help in her own counseling of patients about prophylactic mastectomy.
Post-mastectomy Breast Reconstruction
In another study on mastectomy presented at the meeting, researchers from Beth Israel Medical Center in New York City found that—contrary to what might have been expected—legislation there in 2011 mandating New York physicians to provide information on and access to post-mastectomy breast reconstruction has not significantly increased the breast reconstruction rate.
This study, which aimed to investigate the early impact of legislation on reconstruction rates in an urban, multidisciplinary cancer center, was based on a retrospective chart review of 258 patients undergoing mastectomy in 2010 and 2011. Reconstruction rates were analyzed based on the timing of the legislation; breast surgeon factors; plastic surgeon faculty status (voluntary versus full-time); the type of reconstruction (implant versus autologous); patient age; race; insurance type; disease stage; and mastectomy type (unilateral versus bilateral).
The overall reconstruction rate was found to be about 57 percent, with no statistically significant increase since the 2011 law. Patients who were Asian, older than 60, had stage III or IV cancer, or whose breast surgeon was male were less likely to receive post-mastectomy breast reconstruction.
In addition, patients who received breast reconstruction from a full-time plastic surgeon were more likely to have autologous tissue reconstruction. The researchers, led by Mazen E. Iskandar, MD, a surgeon at Albert Einstein College of Medicine-Beth Israel Medical Center, concluded that “breast cancer reconstruction rates are affected by patients' breast surgeon gender, race, and stage rather than by insurance or legislation.”
Surgeons' Group Takes Tough Stance on Smoking
Also at the Clinical Congress the American College of Surgeons stepped up efforts to involve its members in helping patients quit smoking. The college noted that an estimated 10 million procedures involving smokers are done every year in the United States. However, even though surgeons may ask patients if they smoke (knowing that smoking can lead to unwanted complications and adverse outcomes), fewer than 25 percent of general surgeons advise their patients to quit smoking before elective surgery, and only 13 percent provide smoking-cessation counseling, according to data from the organization.
The surgeons' group noted that: controlled trials show that:
* a cessation intervention at the time of the surgical consultation can help smokers quit, even if it lasts as little as three minutes;
* smoking cessation results in a major drop in postoperative complications;
* about 75 percent of smokers who undergo surgery want to quit; and
* elective surgery provides a powerful teaching opportunity to counsel smokers on quitting.
At the Congress, the organization showcased a new professional e-learning resource, “Quit Smoking before Surgery,” and during a panel session, surgeons also discussed information on the proposed inclusion of a smoking-cessation quality measure for surgeons by the Centers for Medicare & Medicaid Services in the Medicare Physician Quality Reporting System.