The American Society of Breast Surgeons (ASBrS) recently issued a position statement recommending against contralateral prophylactic mastectomy (CPM) for average risk women with unilateral breast cancer. The ASBrS statement published as a pair of manuscripts in the Annals of Surgical Oncology addresses the growing trend to remove the healthy breast in women undergoing mastectomy for breast cancer. The statement follows extensive research and was crafted by a panel of ASBrS experts with the approval of the organization's membership (http://dx.doi.org/10.1245/s10434-016-5443-5, http://dx.doi.org/10.1245/s10434-016-5408-8).
In the position statement, ASBrS encourages an evidence-based approach to determine the value of CPM in breast cancer patients. Research reveals the majority of women with breast cancer obtain no oncological benefit from removal of a healthy breast, although it is appropriate for certain high-risk groups.
“Contralateral prophylactic mastectomy is a growing trend that has generated significant discussion among physicians, patients, breast cancer advocates, and media,” commented Judy C. Boughey, MD, FACS, Professor of Surgery at Mayo Clinic, Rochester, Minn., and lead author of the position statement. “This consensus statement examines and summarizes the data, offers guidelines about appropriateness of prophylactic surgery, and provides a framework for patient discussion. When discussing CPM with patients, it is important for patients to understand it does not improve their cancer outcome and for them to understand the pros, cons, and alternatives to CPM.”
“Typically, the decision to perform a contralateral procedure is based on a combination of the patient's perceived risk and fear of future breast cancer, anxiety about annual screening and possible additional diagnostic procedures, as well as the uncertainty of physical, emotional, and cosmetic surgical outcomes,” said Julie A. Margenthaler, MD, FACS, Professor, Division of General Surgery at Washington University School of Medicine, St. Louis, Mo., senior author of the position paper.
“The society believes that a final treatment plan should be based largely on an analysis of the risks and benefits of contralateral mastectomy and the patient's perspective on surgery,” she adds. “Patient education on those risks and benefits, all treatment options, and recurrence risks are crucial. A well-planned patient-surgeon discussion to facilitate this is extremely important.”
Breast Surgeon's Role
The ASBrS statement suggests surgeons should make a clear recommendation for or against CPM from a medical standpoint to each individual patient and the procedure should generally be discouraged in average risk women, whose chance of developing breast cancer in the opposite breast is 0.1-0.6 percent per year. It recommends counseling for breast conservation for all medically appropriate patients and for use of neoadjuvant or oncoplastic approaches to help facilitate this when appropriate.
The position paper is consistent with the ASBrS contribution to the American Board of Internal Medicine's Choosing Wisely Campaign statement, “Don't routinely perform a double mastectomy in patients who have a single breast with cancer.”
Importantly, the ASBrS paper acknowledges the patient's values and preferences should be an important part of a shared decision-making process. The document provides a detailed template for these discussions, which it highly recommends surgeons follow.
Review of the Mastectomy
Based on a comprehensive review of relevant studies, the paper points out CPM has not been clearly associated with survival benefits for high-risk groups other than BRCA1/2 carriers. However, it also recommends CPM consideration for small, discrete patient populations, including those with a lifetime breast cancer risk greater than 25 percent if they have not had genetic testing and for those with a history of mantle radiation prior to age 30. For women with other genetic risks and with strong family histories but no genetic risk, CPM also may be considered.
Additionally, the paper states CPM may be appropriate for women with other conditions such as dense breasts, recall fatigue, concern about reconstruction symmetry, and extreme disease-related anxiety.
The ASBrS statement emphasizes that, while counseling patients about CPM is essential, performance of the procedure is not an appropriate quality measure. CPM is not associated with improved outcomes, and quality scoring may potentially lower access to CPM for those it may benefit, if the procedure is generally viewed as unnecessary and adding significant risk.
“Counseling patients about CPM and refinement of patient-surgeon decision-making models is one of the best ways we can help women make medically sound choices with comfort and confidence,” said Deanna Attai, MD, Assistant Clinical Professor of Surgery at the David Geffen School of Medicine at UCLA.