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September 03, 2014 - 08:09 am Posted in Featured comments0 Comments

September 2, 2014 — The 2014 Breast Cancer Symposium got a jump start at a pre-meeting Presscast highlighting 5 newsworthy studies to be presented in San Francisco later this week. Three studies focus on issues related to  preventive mastectomy and breast reconstruction surgery, and two other studies explore methods of encouraging repeat screening mammography and factors that predict loco-regional breast cancer recurrence in higher-risk breast cancer.

Genetic counseling and prophylactic double mastectomy

Celebrity publicity about health matters appears to pay off, according to a retrospective study. During the 6 months following Angelina Jolie’s announcement of her BRCA mutation status and subsequent prophylactic double mastectomy, there was a huge increase in requests for genetic counseling and testing at an academic cancer center in Ontario, Canada.  Moreover, this increase was observed among women with a positive family history of breast cancer – the population most at risk.

During the 6-month period after Angelina Jolie’s revelation, referrals for genetic counseling increased from 487 to 816 — 90% — and the number of women who qualified for genetic testing increased from 213 to 437 (about 105%). The number of BRCA carriers identified increased by about 100% (from 29 before her announcement to 61 after).

“This is a real triumph for public disclosure,” stated Presscast moderator Harold Burstein, MD, Dana-Farber Cancer Institute, Boston, MA.

“Early detection of mutational status will help lower the incidence of breast cancer and ovarian cancer diagnosis, with preventive surgeries like mastectomy and oophorectomy. For women who already have breast cancer, a finding of BRCA positivity can increase the uptake of preventive treatments to reduce the risk of a second breast cancer,” said study author Jacques Raphael, MD, clinical fellow at Sunnybrook Odette Cancer Center in Toronto, Canada.

Double mastectomy versus single mastectomy

Over the past decade, there has been a trend toward increased use of double mastectomy in women diagnosed with breast cancer, even in women with single-sided breast cancer. Many women who opt for double mastectomy are average risk and will not derive additional survival benefit from double mastectomy versus single mastectomy. Thus, there is a need for more data on the risks of single versus double mastectomy. At the Presscast, Mark Sisco, MD, University of Chicago Pritzker School of Medicine, presented results of the largest series of analysis to date that examined 30-day complication rates of single versus double mastectomy with reconstruction.

The analysis included 18,000-plus women diagnosed with breast cancer who participated in the American College of Surgeons national Surgical Quality Improvement Program. Results showed that although complications are rare for either type of surgery (overall rate, 5.3%), double mastectomy is associated with higher rates of implant loss and reoperation, need for transfusion, and longer hospital stays, compared with single mastectomy.

In the study, almost two-thirds of women underwent single mastectomy, and slightly more than one-third, double mastectomy with reconstruction.  In both groups, 15,000 women received implant-based reconstruction rather than autologous-based reconstruction: 88.6% of the bilateral surgery group and 79.4% of the unilateral surgery group.

“These findings are reassuring for women who are considering mastectomy with reconstruction and provide additional information that may inform their choice of surgery,” Dr. Sisco said. The information should aid in decision-making between single and double mastectomy, he added.

Commenting on this study, Dr. Burstein said: “The take-home points are that complications are infrequent and medical complications are unaffected by the choice of double versus single mastectomy with reconstruction. But three complications are higher with double mastectomy: implant loss, reoperation, and bleeding requiring transfusion.  These are some of the first data we have seen that allow surgeons to quantify these risks for patients.”

A separate study related to the growing use of double mastectomy focused on factors influencing choice of preventive double mastectomy versus single mastectomy among 150 women newly diagnosed with breast cancer. This is one of the first studies to look at women’s surgical preferences prospectively, prior to undergoing surgery. The study found that women with higher anxiety levels and less knowledge about breast cancer recurrence and survival were more likely to choose double mastectomy than single mastectomy.

“There is so much information out there and patients can become easily overwhelmed. It is our job as doctors to be aware of each patient’s level of knowledge and concerns. We need to do a better job of educating patients that the risk of developing contralateral breast cancer is actually low, and that breast cancer can come back in other parts of the body regardless of the type of surgery they have,” said lead author Katharine Yao, MD, Director of the Breast Surgical Program at NorthShore University HealthSystem, Evanston, IL, and clinical associate professor of surgery at the Pritzker School of Medicine, University of Chicago.

The survey included 55 questions related to knowledge about breast cancer recurrence and survival, general anxiety and depression, and surgery preference. Overall, 59% of respondents chose lumpectomy, 32% single mastectomy, and 9% double mastectomy. Twenty-four percent of women said they did not want to consider double mastectomy, 11% said they did not think it was an option, and none of these two groups chose double mastectomy. Fifty-eight percent (83 women) considered double mastectomy, and twenty-one percent (12 women) underwent double mastectomy.

“Almost all women diagnosed with breast cancer think about double mastectomy,” Dr. Burstein commented. “The anxiety is understandable. We can address the knowledge gap with a multi-disciplinary effort. Personal preference remains important.”

Adding the personal touch to increase repeat screening

A study from the British Columbia Cancer Agency, in BC, Canada, showed that a low-tech intervention –family physician-signed reminder letters – boosted uptake of screening mammography in women who were overdue for screening. These personalized reminders were added to the standard schedule of postcard reminders for medical appointments. Over a 6-month period, the rate of return mammography screening was 22% among women overdue for screening who received only postcard reminders, and the rate rose to 33% if they received a personalized letter from their physicians.

This good news reminds us that technology advances are not the only way to increase screening uptake. Lead author Elisa Chan, MD, formerly with the BC Cancer Agency and now a radiation oncologist at Saint John Regional Hospital in New Brunswick, Canada, and Assistant Professor at Dalhousie University, said “A very simple intervention from a family physician can make a big difference in improving the overall screening mammography return rate.”

“A simple human touch increased rescreening rates by about 70%. This is tribute to the power of personal connection. Oncologists need to work with their primary care networks to improve rescreening rates,” Dr. Burstein commented.

Predicting loco-regional recurrence following neoadjuvant therapy

The fifth study featured at the Presscast identified 2 factors that can predict loco-regional recurrence (LRR) following neoadjuvant therapy in patients with stage I to III breast cancer: pathological complete response to neoadjuvant therapy (pCR, meaning no residual cancer) and tumor subtype. This study is preliminary and more research is needed to substantiate these findings; however, both factors should be considered when trying to select the best treatment options after neoadjuvant therapy, said lead author Eleftherios Mamounas, MD, Medical Director of the Comprehensive Breast Program at the UF Health Center in Orlando, FL, and Professor of Surgery at the University of Central Florida.

The study was an analysis of 12 large clinical trials that included a total of 11,995 women with stage I to III breast cancer who received neoadjuvant chemotherapy prior to surgery. At a median follow-up of 5.4 years, the overall rate of LRR was 8.3%. The study showed that having a pCR to neoadjuvant chemotherapy was protective against loco-regional recurrence.  Women who had residual disease in the breast after neoadjuvant chemotherapy were 1.6 times more likely to recur compared to those with pCR; and those with residual disease in both the breast and the axillary lymph nodes were 2.8 times more likely to recur than those with pCR. The effect of pCR was seen in patients who went on to mastectomy as well as those treated with lumpectomy plus radiation.

Tumor subtype was also a predictive factor. The lowest recurrence rate was in women with hormone-receptor-positive (HR+)/HER2-negative, Grade 1 and 2 tumors; at 5 years, these patients had an LRR rate of 4.2%. All other tumor subtypes had an elevated risk of LRR. For example, women with HR+/HER2-negative, Grade 3 breast cancer had a 9.2% risk of LRR; triple-negative breast cancer patients had a 12.2% LRR rate; HR+/HER2-positive breast cancer had an LRR rate of 9.7%; and women with HR-negative/HER2-positive breast cancer had an LRR rate of 14.8%.

“These data add to our knowledge base and provide a complicated matrix that helps us understand the risk of LRR. This is ‘insider baseball’ data that set the table for deciding which patients require more aggressive therapy and which ones need less,” Dr. Burstein said.

By Alice Goodman

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