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Originally published as JCO Early Release 10.1200/JCO.2005.08.903 on October 3 2005 © 2005 American Society of Clinical Oncology.
Contralateral Prophylactic Mastectomy: Efficacy, Satisfaction, and RegretLombardi Comprehensive Cancer Center, Georgetown University, Washington, DC The risk for development of a contralateral breast cancer among breast cancer patients and survivors is approximately 1% per year. However, for patients who carry a BRCA1 or BRCA2 mutation the annual risk for contralateral cancer is approximately 3% and the overall risk may be as high as 52% by age 70 years.1-3 Given the high rate of contralateral breast cancer, contralateral prophylactic mastectomy (CPM) has long been an option for breast cancer patients who have a strong family history of breast cancer. Throughout the last few years, however, a number of factors have converged to raise awareness and acceptability of CPM. First, the advent of BRCA1/BRCA2 mutation testing has allowed for the more accurate characterization of risk among breast cancer patients. Second, the efficacy of CPM in reducing risk for contralateral breast cancer has been confirmed.4-6 Recent research suggests that in addition to the roughly 90% reduction in the incidence of contralateral breast cancer, CPM may also be associated with a significant reduction in breast cancer mortality.6 These reports coincide with at least two recent studies confirming high rates of CPM among recently diagnosed breast cancer patients when they learn that they carry a BRCA1 or BRCA2 mutation.7,8 Thus, CPM is an effective intervention that is increasingly considered an option for both newly diagnosed and previously diagnosed breast cancer patients who have a strong family history or are known carriers of a BRCA1 or BRCA2 mutation. Despite the efficacy and increased acceptance of CPM in the management of patients at the highest risk for contralateral breast cancer, there have long been unanswered questions and concerns about the psychosocial implications of the procedure. The report by Frost et al9 in this issue of the Journal of Clinical Oncology is the first to evaluate long-term satisfaction or regret and other psychosocial outcomes in a large cohort of women who chose CPM. The authors utilized a unique historical cohort of women with both a personal and family history of breast cancer who received CPM between 1960 and 1993. These patients were contacted at a mean of 10.3 years post-CPM to complete a follow-up survey designed to assess long-term satisfaction and psychosocial outcomes. Of 621 living cohort members, the authors successfully contacted and surveyed 583 participants. This cohort reported extremely high satisfaction with CPM. In fact, the overall satisfaction with CPM was higher than the satisfaction with bilateral mastectomy reported by participants in this group's previous study of high-risk women without a diagnosis of breast cancer.10 Specifically, 83% of participants in this cohort reported that they were satisfied or very satisfied with their decision, and only 9% of the cohort reported dissatisfaction. Unsurprisingly, 83% reported that knowing what they know now they would probably or definitely choose CPM again, compared with only 9% who would not choose CPM again. Given the efficacy of CPM and the extremely high satisfaction following CPM, should high-risk breast cancer patients routinely be provided with recommendations for CPM? There are a number of caveats. Despite the high overall satisfaction in this sample, many participants reported one or more adverse outcomes. One third of participants reported an adverse impact of CPM on body appearance, 26% reported a diminished sense of femininity, 23% reported negative effects on sexual relationships, and 17% reported diminished self esteem. Further, 27% of all participants required one or more unanticipated reoperations, usually due to complications with reconstruction. These adverse psychosocial and surgical outcomes were associated with dissatisfaction. Specifically, patients who had subcutaneous mastectomy, reconstruction, or who required unanticipated reoperations reported greater dissatisfaction or less willingness to have CPM again. In terms of psychosocial factors, women who reported that CPM had an adverse impact on their body appearance, sense of femininity, or sexual relationships were less satisfied with the decision to undergo CPM. The majority of participants reported at least one adverse outcome. Together with the earlier report by this group, documenting high rates of satisfaction with bilateral prophylactic mastectomy,10 this report provides the most complete and compelling data yet on psychosocial outcomes following prophylactic surgery. The reported satisfaction with CPM in this cohort must be considered in light of the 40 years that have passed since the establishment of this cohort. At the time of diagnosis, many of the women in this cohort did not have the option of breast conservation. Today, most of these patients would be candidates for conservative treatment. There is some evidence that compared with women who are candidates for breast conservation, those who require mastectomy may be more likely to choose CPM.7 In fact, the decision to remove a healthy breast may be far more difficult, and may have a greater potential for subsequent regret among patients who have the option of lumpectomy. Another change that has taken place since the establishment of this cohort is the diminished role of subcutaneous mastectomy. In this report, patients who received a subcutaneous mastectomy reported superior cosmetic outcomes, but lower overall satisfaction. Similarly, reconstruction and unanticipated reoperations due to complications associated with reconstruction were also related to dissatisfaction. Given the current infrequent use of subcutaneous mastectomy, coupled with advances in surgical and cosmetic outcomes of breast reconstruction, it may be reasonable to assume that these predictors are of less relevance today than they were at the time that this cohort underwent CPM. Perhaps the most relevant change in the years since this cohort was established is the advent and widespread availability of genetic testing. Participants in this report received CPM before the availability of such testing. The impact of knowing one's carrier status on the decision to obtain CPM has been demonstrated.7 However, the long-term psychosocial impact of CPM following genetic testing has not been evaluated. Certainly genetic counseling and testing have the potential lead to more fully informed decisions regarding breast cancer risk management. To the extent that decisions are more fully informed, patients may be more satisfied during the long-term. On the other hand, the availability of genetic testing may lead to increased frequency and strength of physician recommendation for CPM. If such recommendations lead patients to opt for CPM despite their own misgiving, this could have an adverse effect on psychosocial outcomes. In fact, in this group's earlier study, unaffected patients who received a physician recommendation for bilateral mastectomy were ultimately less satisfied with that decision compared to women who did not report a physician recommendation.10 Further, for individuals who receive uninformative genetic test results, decision making regarding CPM may be made even more difficult. There are also some methodologic issues that complicate the interpretation of the data in this report. As the authors acknowledge, this cross-sectional study can only provide a psychosocial snapshot at a mean of 10 years post-CPM. These data do not address adaptation to CPM in the first few years following the surgery. In fact, these early years may be the period in which patients are most vulnerable to adverse psychosocial outcomes. Equally important is that, without prospective data, it is not at all clear that the psychosocial outcomes reported are actually a consequence of surgery. For example, although one third of the cohort reported decreased satisfaction with their appearance following CPM, there are no prospective data to document ratings of body image before surgery. Similarly, without a control group of women who opted against CPM, it is impossible to determine whether CPM is associated with enhanced or diminished psychosocial outcomes. Future studies must prospectively and longitudinally address the psychosocial impact of CPM using well-validated measures and a matched control group of women who chose not to undergo CPM. Despite some limitations, this study provides valuable and compelling data regarding the long-term psychosocial implications of CPM. Although adverse outcomes were fairly common, the vast majority of participants were satisfied with their decision to obtain CPM and would repeat the decision if faced with the choice again. From a clinical standpoint, concerns about adverse psychosocial outcomes should not be an impediment to raising the option of CPM with high-risk patients. However, each patient should be counseled fully regarding the medical and psychosocial risks and benefits of CPM. Such counseling should acknowledge the generally positive adaptation of most women who have chosen this procedure. However, it is equally important to discuss the potential for adverse outcomes. In particular, it is critical to address those outcomes that were associated with diminished long-term satisfaction, such as body image, sexual functioning, and the potential for re-operations following reconstruction. Clearly, additional data are needed to determine whether there are variables that prospectively predict adverse outcomes. Until such data are available, however, physicians and patients should be reassured by the generally positive outcomes associated with CPM. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Metcalfe K, Lynch HT, Ghadirian P, et al: Contralateral breast cancer in BRCA1 and BRCA mutation carriers. J Clin Oncol 22:2328-2335, 2004
2. Breast Cancer Linkage Consortium: Cancer risks in BRCA2 mutation carriers: The Breast Cancer Linkage Consortium. JNCI 91:1310-1316, 1999 3. Verhoog LC, Brekelmans CT, Saynaeve C, et al: Contralateral breast cancer risk is influenced by the age at onset in BRCA1-associated breast cancer. Br J Cancer 83:384-386, 2000[CrossRef][Medline] 4. Peralta EA, Ellenhorn JD, Wagman LD, et al: Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer. Am J Surg 180:439-445, 2000[CrossRef][Medline]
5. McDonnell SK, Schaid DJ, Myers JL: Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer. J Clin Oncol 19:3938-3943, 2001
6. Herrinton LJ, Barlow WE, Yu O, et al: Efficacy of prophylactic mastectomy in women with unilateral breast cancer: A cancer research network project. J Clin Oncol 23:4251-4253, 2005
7. Schwartz MD, Lerman C, Brogan B, et al: Impact of BRCA1/BRCA2 counseling and testing on newly diagnosed breast cancer patients. J Clin Oncol 22:1823-1829, 2004
8. Weitzel JN, McCaffrey SM, Nedelcu, et al: Effect of genetic cancer risk assessment on surgical decisions at breast cancer diagnosis. Arch Surg 138:1323-1328, 2003
9. Frost MH, Slezak JM, Tran NV, et al: Satisfaction after contralateral prophylactic mastectomy: The significance of mastectomy type, reconstructive complications, and body appearance. J Clin Oncol 23:7849-7856, 2005
10. Frost MH, Schaid DJ, Sellers TA, et al: Long-term satisfaction and psychological and social function following bilateral prophylactic mastectomy. JAMA 284:319-324, 2000
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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