Some women who have been diagnosed with early-stage breast cancer in one breast choose to have that breast and the other healthy breast removed. Usually, the healthy breast is removed because of understandable fears that a new, second breast cancer might develop in the other breast. This procedure is called prophylactic mastectomy.
The research reviewed here found that looking at a woman's breast cancer risk profile and the "personality" of the breast cancer can help doctors figure out which women would benefit the most from prophylactic mastectomy.
Women who've been diagnosed and treated for early-stage breast cancer in one breast have a higher-than-average risk of developing a new, second cancer in the other breast. This risk is very high for some women and only somewhat higher-than-average for other women. If risk is very high, doctors may recommend prophylactic mastectomy. Even without a doctor's recommendation, some women choose prophylactic mastectomy because they understandably fear another breast cancer. Some women request prophylactic mastectomy to have more balanced cosmetic results after reconstructive surgery on both breasts.
Researchers looked at the medical histories of more than 500 women diagnosed with early-stage breast cancer who had prophylactic mastectomy and compared them to the medical histories of more than 1,500 women also diagnosed with early-stage breast cancer who chose not to have prophylactic mastectomy.
The analysis was complex because many factors varied from woman to woman:
These variations made it harder to figure out which women would benefit the most from prophylactic mastectomy.
Still, the results showed that a small group of women with a specific breast cancer risk profile diagnosed with breast cancer with certain characteristics got the most benefits from prophylactic mastectomy:
Women with any of these three factors were more than three times more likely than women who did not have any of these factors to develop breast cancer in the opposite breast. So the researchers concluded that prophylactic mastectomy makes the most sense for women with any one of these three factors.
If you've been diagnosed with early-stage breast cancer, ask your doctor about ALL of your treatment and risk reduction options. Prophylactic mastectomy is only one of these options and is a very aggressive step. While that may be the right decision for you, talk to your doctor to make sure that your decisions are based on your real risk, not only fear. Talk about your Gail score and how the cancer details in your pathology report may affect your future risk. Together, you and your doctor can make the decisions that are best for you and your unique situation.
The National Cancer Institute's Gail score page has more information about the tool.
HOUSTON, Jan. 26 (MedPage Today) -- Characteristics of both the tumor and the patient may help determine who would benefit from prophylactic contralateral mastectomy, researchers said.
Factors predictive of contralateral malignancy included five-year Gail risk of 1.67% or higher and an ipsilateral tumor with moderate- to high-risk pathology, multicentric location, or invasive lobular histology, Kelly K. Hunt, M.D., of the University of Texas M.D. Anderson Cancer Center, and colleagues reported in the March 1 issue of Cancer.
Using these factors to define the risk when counseling patients may help to reduce the rate of contralateral prophylactic mastectomy, especially since patients have less extreme options for risk reduction, the researchers said.
Other strategies to reduce contralateral breast cancer risk include systemic chemotherapy and endocrine therapy and the use of MRI along with mammography to improve contralateral breast cancer detection, they noted.
Patients most often choose contralateral prophylactic mastectomy on the advice of their physician or because of their own fear of developing another breast cancer, desire for cosmetic symmetry, family history, or fibrocystic breast disease that makes surveillance more challenging.
However, "most patients will not experience any survival benefit," the researchers noted, "because the risk of systemic metastases from their index cancer often exceeds the risk of developing a contralateral breast cancer."
To determine what factors might determine which patients would benefit, the researchers analyzed findings for 542 unilateral breast cancer patients who underwent prophylactic contralateral mastectomy at M.D. Anderson over a seven-year period.
These patients were found to have a low risk of occult cancer in the contralateral breast (4.6%).
By comparison, the incidence of contralateral breast cancer was 0.56% per year (2.4% at 50.2 months) among a tumor stage-, age-, and race-matched control group of 1,574 breast cancer patients who did not chose prophylactic contralateral mastectomy.
This finding suggested that contralateral prophylactic mastectomy "led to early detection and resection of already existing contralateral breast cancers more than prevention of expected contralateral cancers," the researchers noted.
In the overall multivariate analysis, the independent factors predictive of a malignancy in the contralateral breast were:
When the findings were stratified by whether patients received neoadjuvant chemotherapy, the independent predictive factors among those who didn't receive chemotherapy were an ipsilateral multicentric tumor (OR 3.7, P=0.03) and high five-year Gail risk (OR 4.6, P<0.0001).
But only ipsilateral invasive lobular histology (OR 21.3, P=0.0009) was predictive among those who got chemotherapy.
Dr. Hunt's group acknowledged that their study was limited by its single-institutional, retrospective design and the relatively short follow-up time. "Whether the contralateral breast cancer incidence will remain low in our contralateral prophylactic mastectomy cohort remains to be determined."
The researchers reported no conflicts of interest.
Primary source: Cancer Source reference: Yi M, et al "Predictors of Contralateral Breast Cancer in Patients With Unilateral Breast Cancer Undergoing Contralateral Prophylactic Mastectomy" Cancer 2009; 115.
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