Medical Device Daily Senior Staff Writer

An astonishing 92% of breast cancer patients who elected to have a contralateral prophylactic mastectomy (CPM; removal of the second healthy breast) to minimize risk of a second cancer are still satisfied with their decision even 20 years later, according to a study presented Friday at the annual meeting of the American Society of Breast Surgeons (ASBrS; Washington). The research found that while many acknowledged adverse effects, the psychosocial implications of their decisions did not increase over time and 92% of survey participants said they would make the same choice today.

Researchers at Mayo Clinic (Rochester, Minnesota) surveyed women diagnosed with unilateral breast cancer who had undergone a CPM in their facility between 1960 and 1993. An initial questionnaire was completed an average of 10 years after the elective surgery. On Friday, researchers reported results of a follow-up survey completed by 269 of these women an average of 20 years after their surgeries.

"We found remarkable stability across the two surveys on participation satisfaction," said Judy Boughey, MD, a researcher involved with the study. "In fact, when women changed their opinions, they generally indicated greater, rather than less, comfort with their choice."

Patients who already have had breast cancer are at slightly greater risk for a second cancer than the general population. Further, many women who chose prophylactic mastectomies have breast cancer family histories, compounding their chances of a contralateral breast cancer.

The first survey found that 86% of participants were satisfied 10 years after their procedures, while 90% indicated satisfaction after 20 years. Only 6% reported dissatisfaction with their decision, and that figure remained constant across both questionnaires, the researchers noted. In the recent survey, 93% felt they made an informed decision that reflected their overall values. Almost 80% of these women also had breast reconstruction.

When recounting the adverse effects, patients frequently cited body appearance, sense of femininity and sexual relationships. This remained constant over time.

"It's hard to talk about contralateral prophylactic mastectomy – and really not appropriate to talk about contralateral prophylactic mastectomy – without talking about some of the adverse effects [sexual and emotional]," Boughey told participants during the annual ASBrS meeting, which was also webcast.

"There is remarkable stability of satisfaction with decision to undergo CPM over 20 years after surgery. Adverse psychosocial effects do not increase over time," she said, which was the conclusion of the study. "Those women who decide CPM is the right decision for them, they are likely to remain satisfied with that decision."

During her slide presentation, Boughey shared some of the comments that the study participants made describing the positive impact of their choice to have an elective CPM. One such patient noted that by having a prophylactic mastectomy her many of her fears were erased. "Not 100%, but close to it."

Noting that prophylactic mastectomy rates have been steadily increasing, Boughey said that knowing few women regret their decisions should help reassure those facing this difficult choice today. However, she advises all women to consider such a decision carefully and to balance the negative consequences of mastectomy with their risk of cancer recurrence and need to achieve peace-of-mind.

"Because patients in our survey showed a high degree of satisfaction doesn't mean the choice is right for everybody," she said. "This is a deeply personal decision. Understanding all the consequences is extremely important."

The reason for this study, the researchers noted, was because little was previously known about the consistency of satisfaction and changes in adverse effects in the same women with longer term follow-up.

Another study presented during the meeting found that mammography detects smaller breast tumors with less nodal involvement than clinical (manual) exams in women under age 50 and that the new U.S. Preventative Services Task Force (USPSTF; Washington) mammography guidelines could potentially impact survival in younger patients. The study was a 10-year retrospective study conducted at the University of Missouri School of Medicine (Columbia).

"Breast cancer has a better prognosis when treated before tumors become palpable and identifiable through a physician or self-breast exam," said researcher Paul Dale, MD, chief of surgical oncology at the Ellis Fischel Cancer Center at the University of Missouri School of Medicine. "The study also found that tumors identified through mammography generally had better outcomes after treatment than those found through clinical exams."

Dale noted that while the results of the study were not surprising based on his experience, the limited amount of research examining how the new guidelines might impact breast cancer mortality was unexpected. "Despite significant objections to these new guidelines, few researchers have specifically looked at mammography and its long-term impact on outcomes in younger women. This study provides important new information."

Dale and his team looked at patients treated for breast cancer at the tertiary referral center between 1998 and 2008. Of these 1581 women, 20% were between the ages of 40 and 49, 47% of these patients were diagnosed through mammography and 53% through clinical exams or other non-mammographic methods. In the mammography group, the mean tumor size was 20 mm in diameter, while non-mammographically identified tumors were 30 mm. Dale said that this difference in tumor size is highly significant. The study also found that the frequency of lymph node involvement in the clinically detected groups was about twice that of mammographically detected patients.

In the study, five year disease-free survival rate was estimated statistically by using survival analysis methodology to be 94% for the group receiving mammograms and 78% for those who did not receive the screening exams. Node negativity and tumor size were significantly associated with an increase in survival.

"This study found that 20% of women diagnosed with breast cancer in our institution are under age 50, and almost half of their tumors were detected through mammography. Given recent advances in targeted treatment of early stage cancer, under these new guidelines, younger breast cancer patients not undergoing screening and early detection may miss out on important therapy that could significantly impact their survival," Dale said.

He added that many of the studies evaluated for revision of the USPSTF guidelines pre-date digital mammography and that full-field digital mammography has recognized benefits over plain film exams for younger patients with difficult-to-image dense breast tissue. "One concern underlying the new recommendations is that mammography in younger women is less effective and results in too many biopsies that are unnecessary and potentially traumatic for patients. Perhaps today's advancing imaging technologies, as well as less invasive biopsies, will help to eliminate those concerns."

Amanda Pedersen, 309-351-7774;

amanda.pedersen@ahcmedia.com

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