RISK REDUCTION MASTECTOMY
 Breast cancer -frequently diagnosed malignancy in women
 Incidence: 127.5 per 100,000 women per year
 BRCA1/2 confer 65- 85 % lifetime risk for breast cancer (BC)
 Surgical treatment options : Breast conservation surgery and mastectomy
 Women with breast cancer- risk of contralateral breast cancer : 0.4% per year
FACTORS INFLUENCING CONTRALATERAL BREAST CANCER
(CBC) RISK
 Patients with breast cancer: annual risk 0.4 %

1.3 – 1.9 times the risk of first breast cancer in general population
• BRCA1/2- strongest risk factorAnnual risk 2-3 %
• Other germline mutation
• Family history- doubles the risk
• Young age
• Lobular histology
• High grade tumor
• High density breast
• Risk reduction mastectomy –
RRM
• Treatment of first breast
cancer: Systemic treatmentendocrine, chemotherapy and
trastuzumab
PREDICTION MODELS
 Three contralateral breast cancer risk prediction models
Manchester
formula
 Patient and tumor characteristics taken into consideration
CBCrisk
 re-calibration is required – before using in clinical decision-making
PredictCBC
 Risk-reducing mastectomy - most effective options to decrease the risk of
developing cancer
 ‘Angelina Jolie effect’: more women have been tested for the BRCA1 and BRCA2
mutations, and more women have opted for prophylactic mastectomies to greatly reduce
their risk of developing breast cancer
 increase anxiety as well as awareness
RISK REDUCTION MASTECTOMY - RRM
Bilateral RRM
Prophylactic
mastectomy
Risk
Reducing
Mastectomy
• Removal of both breast in asymptomatic women
Contralateral RRM
• Removal of unaffected breast when bilateral
mastectomy is performed for the management
of unilateral breast cancer
Surgical
removal of
breast in the
absence of
malignancy
The decision to undergo RRM is preference-sensitive.
Risks
• Increased risk of operative or
postoperative complications
• Cosmetic, sexual and emotional effect
• Potential need for follow up procedure
Benefits
• Decreased risk of contralateral breast
cancer
• Diminished need for surveillance
• Cosmetic symmetry
Meta-analysis
n = 2635
BRCA 1/2 positives receiving BRRM
Significant risk reduction of breast cancer
incidence
HR 0.07; 95% CI 0.01-0.44; P= 0.004
 improvement in survival- debate ongoing.
 Asymptomatic BRCA gene mutation carrier population - bilateral RRM - most effective option for breast cancer risk
reduction.
RISK REDUCTION MASTECTOMY RATES AND TRENDS
 Nearly threefold increase in RRM uptake 2004-2012

All age groups:

Breast cancer stage I- III

Especially younger women <40 ys, non Hispanic whites, privately insured
 Patients with low risk of contralateral breast cancer contribute to upward trend
SURGEONS’ INFLUENCE ON PATIENT DECISIONS.
 large influence on patient’s decision
 Surgeons knowledge vary widely
 Wide variation between surgeons in recommendations and
approaches to the discussion with the patient
PATIENT RATIONALES FOR RRM
Will RRM reduce mortality risk?
• No survival benefit after RRM compared to BCS
• Contradictory results of survival after primary breast cancer vs after contralateral
breast cancer
Will RRM reduce the risk of contralateral breast cancer?
• Patient perceived risk overestimates calculated risks
• Relative risk 90-96% reduced after RRM
• No or little absolute risk reduction in low risk patients due to low incidence
PATIENT RATIONALES FOR RRM
Can I avoid future screening with RRM?
• NCCN guidelines do not recommend screening after RRM
• However, risk of complications
• RRM more likely after MRI at diagnosis
• Sometimes anxiety and distrust towards screening
Will I have better breast symmetry after RRM?
• 90% satisfaction after RRM
• Cosmetic result, body image
• Factors of satisfaction
• 45% adverse effects
• Concerns after both unilateral mastectomy and RRM
GUIDELINES
•
•
•
•
•
•
•
•
•
RRM only recommended in high-risk situations,
including BRCA1 and BRCA2 and a strong family
history- as “a greater than 25% lifetime risk of breast
cancer primarily due to family history in the absence of
deleterious mutations”.
Options for risk reduction be discussed in a shared
decision-making environment
Patient counseling and informed discussion are
important
Surgeon should make a direct recommendation for or
against RRM to each patient
RRM only recommended in high-risk situations,
including BRCA1/2
Gail model used to identify non mutation carriers at high
risk
Considered in women with a 1.7% 5-year risk of first
primary breast cancer combined with a life expectancy
of 10 years
Options for risk reduction be discussed in a shared
decision-making environment
Patient counseling and informed discussion are
important
NCCN
ASBrS
Manchester
• Preoperative assessment and counselling
• Reasons and clinical history
• Calculating CBC risk
• Giving the patient time for the
decision – cooling off period
• Multi-disciplinary team
discussion
• Patient decision and consent form
RECOMMENDATION
 Patient preference - major factor in the decision making
1
 Address the following
2

impact of RRM on the chance of dying of breast cancer

The chance of experiencing another cancer diagnosis and treatment

The chance of avoiding screening

anxiety management with a psychologist might be useful

reduction in potentially harmful overtreatment
3
4
• informing the patient that a decision needs to be
made and that the patient’s opinion is important
• available options and the pros and cons
• patient’s preferences and deliberation, patient’s
wish to make a decision, or defer the decision
• discuss follow-up
BREAST CANCER RISK-REDUCING STRATEGIES ACCORDING TO
CATEGORY OF RISK
 High-risk germline variants / chest wall radiotherapy < 30 years

BRRM  lower breast cancer risk (potential alternatives : screening and chemoprevention ) OR

CRRM  reduce risk of a new primary cancer in the opposite breast if diagnosed with unilateral breast cancer.
 Asymptomatic carriers of moderate-risk variants  screening and chemoprevention
Unilateral stage I to III breast cancer between 1998 and 2012
7%
BCS
Unilateral mastectomy
33%
CPM
60%
CPM RATES FROM 2002 TO 2012: 3.9%  12.7%
TREND OF CPM
12,70%
14,00%
12,00%
10,00%
2012
8,00%
6,00%
4,00%
(P < 0.001)
3,90%
2002
2,00%
0,00%
CPM
2002
2012
RECONSTRUCTIVE SURGERY
CPM
Unilateral Mastectomy
16%
51,70%
48,30%
74%
Reconstructive surgery
No reconstructive surgery
Reconstructive surgery
No reconstructive surgery
 Rates of reconstruction with CPM rising from 35.3% in 2002 to 55.4% in 2012
TREND OF RECONSTRUCTION WITH
CPM
55,40%
CPM
35,30%
0,00%
10,00%
20,00%
P < 0.001
30,00%
2012
2002
40,00%
50,00%
60,00%
CONCLUSION
 RRM – most effective risk-reducing intervention to prevent breast cancer and breast cancer recurrence.
 Survival benefit is seen for BRRM in BRCA mutation carriers, but no significant survival benefit for CRRM in
non-carriers
 No improvement in BCSS and OS in CPM

BCSS: HR 1.08, 95% CI 1.01-1.16

OS: HR 1.08, 95% CI 1.03-1.14

Irrespective of HR status or age.
 Despite this CPM more than tripled during the study period
 Growing attention around breast cancer prevention, screening and testing in the public - overestimation of contralateral
breast cancer risk.
 Patients -aware of their low risk, but still want to eliminate all risk.
 Patients with breast cancer – want RRM to avoid the need for further screening.
 Options for risk reduction - shared decision-making
 Patient counseling and informed discussion are important.
 Risk stratification and implementation of risk-assessment tools
 Reserve RRM for specific situations

Low risk of contralateral breast cancer (CBC), ipsilateral BCS is the recommended
 Low or intermediate risk of CBC: treat existing disease first  RRM to be delayed until treatment for the primary
cancer is complete
 Personalized information about the risk:benefit balance ratio of RRM
 Informed understanding of risks for CBC  realistic plan for the patient
 Short- and long-term physical effects of RRM
 Psychological and surgical counselling before RRM; anxiety alone is not an indication for RRM
 Specialist breast units - patient-centred pathway.