Editorial
Trend in Performing Mastectomy for Breast Cancer Treatment and Prevention
Helena Chang*
Revlon/UCLA Breast Center, David Geffen School of Medicine at UCLA, USA
*Corresponding author: Helena Chang, Revlon/UCLA Breast Center, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Suite B265, Los Angeles, CA 90095, USA
Published: 29 Dec, 2016
Cite this article as: Chang H. Trend in Performing
Mastectomy for Breast Cancer
Treatment and Prevention. Clin Oncol.
2016; 1: 1168.
Editorial
In recent years, a sharp increase in performing simple mastectomies of various types has been
reported across the nation. Many patients who were traditionally treated by breast conserving
surgery for early breast cancer or modified radical mastectomy for advanced primary cancer are
now choosing simple mastectomy and sentinel lymph node biopsy. The trend of skipping modified
radical mastectomy is no longer limited to those with clinically negative axilla with proven negative
sentinel lymph nodes, and it has been extended to patients who have either limited metastatic
sentinel lymph nodes or those who have pathologically proven metastasis but are converted to node
negative disease by neoadjuvant chemotherapy.
ACOSOG Z0011 study [1,2] demonstrated that among patients with lumpectomy and limited
positive sentinel lymph nodes who had postoperative whole breast radiation, there was no difference
in overall survival and disease free survival rates between groups of patients with and without
axillary lymph node dissection. The same approach has been extended into managing patients with
mastectomy who had limited metastasis found in the sentinel lymph nodes. Fu et al. [3] recently
reported that postmastectomy radiation without axillary lymph node dissection was as effective as
those with axillary lymph node dissection in patients with mastectomy and limited metastasis in
sentinel lymph nodes. Recently, we used the California State Tumor Registry’s database to study
the role of post-mastectomy radiation in patients with T1/2N1a breast cancer detected by sentinel
lymph node biopsy [4]. We found that additional axillary lymph node dissection is not necessary for
these patients if they underwent post-mastectomy radiation [4].
In addition, a recent ACOSOG Z1071 Allian study showed that 41% node positive patients
became node negative after neoadjuvant chemotherapy [5] which further suggested this group of
patients traditionally treated by axillary lymph node dissection now may have sentinel lymph node
biopsy with simple mastectomy.
Parallel to the increasing use of simple mastectomy in treating invasive breast cancer, a growing
trend of simple mastectomy is also observed in treating young women with Ductal Carcinoma
In Situ (DCIS). It is well known that DCIS is associated with an excellent survival outcome after
either breast conserving treatment or mastectomy. For many years, lumpectomy with radiation
was preferred by most for treating DCIS. However, Rutter et al. [6] reported that the rate of using
mastectomy in treating DCIS was rising after 2004.
In addition to the noticeable rise of using mastectomy in cancer treatment, an even more
dramatic trend is choosing contralateral prophylactic mastectomy in women with unilateral breast
cancer [7-9]. While it is not clear what are the reasons responsible for this change, Fu et al. [10]
reported a retrospective analysis of 373 breast cancer patients treated by mastectomy between 2002
and 2010 in a single institution. Of the 373 patients, 55.5% had bilateral mastectomy and 44.5% had
unilateral mastectomy. In this study, younger age, early stage breast cancer, family history of breast
and/or ovarian breast, personal history of BRCA mutation, history of multiple breast biopsies, and
preoperative MRI were found to be associated with having bilateral mastectomy when compared
with the unilateral mastectomy group. Even after excluding those with bilateral breast cancer,
the same predictors for choosing contralateral prophylactic mastectomy remained unchanged.
Similar association factors with contralateral prophylactic mastectomy have also been reported by
others [11-13]. Of the 151 patients reported by Fu et al. with unilateral breast cancer and bilateral
mastectomy, 75% had immediate reconstruction. It is clear that the availability of immediate
reconstruction and improved aesthetic options contribute to the trend of choosing contralateral
prophylactic mastectomy in treating women with early breast cancer [14].
In addition to an overall increase in choosing simple mastectomy
either with or without axillary lymph node surgery for treating breast
cancer, a trend of selecting contralateral prophylactic mastectomy has
been observed across the nation. Many questions remain unanswered
in the practice of contralateral prophylactic mastectomy. The first and
foremost question is whether contralateral prophylactic mastectomy
reduces a second breast cancer event and improves cancer specific
survival. Kruper et al. [15] use SEER – the Surveillence, Epidemiology
and End Results database to compare the outcomes of 26,562
cases of therapeutic mastectomy and contralateral prophylactic
mastectomy with 138,826 cases of unilateral therapeutic mastectomy.
After propensity score matched analysis, the authors found that
contralateral prophylactic mastectomy was associated with better
disease free and overall survival rates in all subset analysis including
patients across all stages of disease and across ER positive and
negative breast cancer groups. However, limitation of SEER database
does not allow removing bias that may affect survival outcomes [16].
Similar observations were also reported by others but all had the same
limitation in data analysis [17].
With contralateral prophylactic mastectomy rates continuing
to rise and an unclear clinical benefit of the procedure, answers for
other associated issues such as complication rate, short and long-term
effects on patient satisfaction and issue of cost-effectiveness have been
scrutinized to better inform patients regarding risks and benefits of
this added procedure has become increasingly important.
Miller et al. [18] assessed complication rates associated with
contralateral prophylactic mastectomy by comparing 209 cases of
contralateral prophylactic mastectomy with 391 cases of unilateral
mastectomy in cancer patients performed in a single institution
between 2009 and 2012. The authors found that the contralateral
mastectomy group was 1.5 times more likely to have any complication
and 2.7 times more likely to have a major complication compared
with unilateral mastectomy group. Other older studies [19,20]
also cautioned the risks of surgical complications after bilateral
mastectomy with or without reconstruction. A more recent study
reported by Silva et al. [21] to compare the complication rates of the
two groups however only showed a modest difference in postoperative
complication rates – 8.8% after unilateral mastectomy and 10.1%
after bilateral mastectomy in overall complication rate and 4.2 and
4.6% respectively for surgical site infection.
In addition to a potential increase in complications because of
added contralateral prophylactic mastectomy, concern for delaying
adjuvant therapy has been raised. Sharpe et al. [22] reported that
bilateral mastectomy was associated with a delay to adjuvant
chemotherapy; however, in multivariate analysis this association was
not significant. There is no delay in receiving adjuvant radiation and
hormonal therapy.
The added cost for contralateral prophylactic mastectomy
is also a concern. According to recent data from a major private
health insurer, the average cost of a bilateral mastectomy with
reconstruction was $30,500 and $18,500 for unilateral mastectomy
with reconstruction. A recent report by Edwards et al. [23] suggested
that in high risk individuals, bilateral mastectomy is cost-effective
compared with subsequent imaging screening based on Medicare
reimbursement rates. The reported cost analysis did not include the
costs for subsequent cancer diagnosis, treatment, and supportive care.
Beyond the concerns of surgical complications and cost
associated with added contralateral prophylactic mastectomy, it is
also important to assess the long term effects of this procedure on
women at the levels of body image, sexuality, and overall health.
Studies were done to compare bilateral mastectomy with those in
the general population, unilateral mastectomy and breast conserving
therapy. Unukovych et al. [24] reported that no difference was found
in health-related quality of life – including anxiety, depression,
sexuality before and after contralateral prophylactic mastectomy
and between women with contralateral prophylactic mastectomy
and those in the general population, although more than half of
the patients reported at least one body image issue at two years
after surgery. When patients with reconstruction after contralateral
prophylactic mastectomy and unilateral mastectomy were compared,
the former group was associated with higher mean score for breast
and outcome satisfaction [25]. Both groups had a similar healthrelated
quality of life (HR-QoL). Sexual dysfunction was observed in
both breast conserving therapy and mastectomy groups. However,
postoperative sexual dysfunction was more significant in patients
after mastectomy. Further subset comparisons between unilateral
mastectomy and bilateral mastectomy with or without reconstruction
was not performed in this study [26].
While mastectomy with or without reconstruction clearly affects
women’s body image and sexuality, Rosenberg et al reported that
80% patients who chose contralateral prophylactic mastectomy
were confident in their decision and 90% would have made the same
decision again [27]. As such, the trend of contralateral prophylactic
mastectomy may continue to rise especially in young women with
breast cancer.
After considering all concerns, a consensual statement from the
American Society of Breast Surgeons recommended that contralateral
prophylactic mastectomy should be discouraged in women with
average-risk and unilateral breast cancer [28].
Historically, mastectomy was performed in women with breast
cancer. However, in the recent decade, advances in molecular
biology have played a key role in identifying women at increased
risk for breast cancer. Although age and family history have always
been recognized as the important factors in determining risk, the
discovery of the BRCA1 and BRCA2 gene mutations associated with
breast cancer risk has provided an objective means to identify women
at high risk for developing breast cancer. These women not only
carry a significantly increased risk of developing breast cancer but
are also more likely to develop it at an early age [29-33]. Therefore,
identification of these patients by genetic testing is critical if any
aggressive measures to reduce the risk of developing breast cancer are
to be considered. Currently, the most effective prevention for breast
cancer is prophylactic mastectomy. However, prospective data are
limited. Guidelines for considering prophylactic mastectomy have
been proposed, but there is no absolute indication for this procedure
[34,35]. These guidelines also recommend that prophylactic
mastectomy may be considered in patients without a history of breast
cancer but who are at increased risk of developing breast cancer or
who have clinical conditions known to make evaluation of the breasts
difficult [34]. Conditions recognized beyond a proven mutation
include atypical hyperplasia with a high risk family history of breast
cancer, lobular carcinoma in situ, history of a first-degree relative
with premenopausal bilateral breast cancer, and dense breasts that
are nodular which make evaluation exceptionally difficult.
A retrospective study of prophylactic mastectomy in women with a family history of breast cancer was reported by Hartmann
and associates [36] at the Mayo Clinic. This study demonstrated
a significantly decreased incidence of breast cancer following
prophylactic mastectomy after a mean follow-up of 14 years. Only 7 of
639 patients developed breast cancer after prophylactic mastectomy.
All of whom developed breast cancer had a previous subcutaneous or
incomplete mastectomy. None of the patients who underwent simple
mastectomy developed breast cancer; however, the difference was not
statistically significant. A similar retrospective study of 1500 patients
by Pennisi and Capozzi [37] showed comparable results.
When genetic testing for inherited breast cancer becomes better
understood and more available, many of these high-risk women may
be attracted to the idea of risk reducing mastectomy. Studies have
also shown that nipple-sparing mastectomy with reconstruction
is safe feasible and preferable by most young women who choose
to have risk reducing mastectomy [38-42]. Currently, BRCA1 or
BRCA2 mutations and several other forms of hereditary breast
cancer seem to be the only agreed upon indication for prophylactic
mastectomy. Women should be thoroughly advised of available data
on risk reduction, extent of surgery that is involved in prophylactic
mastectomy and reconstruction, and the lack of long-term data from
prospective studies before proceeding with this therapy.
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