Surgery News - January 2008 - (Page 22) BREAST, SKIN & SOF T TISSUE SURGERY NEWS • J A N U A RY 2 0 0 8 More Patients Opting for Bilateral Mastectomy BY JANE SALODOF MACNEIL Else vier Global Medical Ne ws ven though most breast cancer patients never develop the disease in the second, cancer-free breast, the proportion of women opting to have both breasts removed more than doubled from 1998 to 2003. The first national study of contralateral prophylactic mastectomy reported that the rate of this procedure rose from 1.8% to 4.5% of all surgically treated patients diagnosed with unilateral stage I, II, or III breast cancer during the 6 years studied ( J. Clin. Oncol. 2007; 25:5203-9). Among just those patients whose cancer was treated by mastectomy, the rate of contralateral prophylactic mastectomy increased from 4.2% to 11%. Younger women, non-Hispanic white women, patients with a previous cancer diagnosis, and those with lobular histology were more likely to opt for double mastectomy, according to researchers from the University of Minnesota public health and medical schools in Minneapolis. Trends toward higher rates were seen in all three cancer stages, however, with no plateau in sight at the study’s end. “These findings represent a dramatic change toward more aggressive breast can- cer surgery in the United States,” Dr. Todd M. Tuttle and his coinvestigators wrote. Dr. Tuttle, chief of surgical oncology at the University of Minnesota, Minneapolis, said in an interview that the investigators conducted the study because they noticed more women with cancer in one breast were asking to have the other breast removed. To see whether this was a more widespread phenomenon, they reviewed treatment of 152,755 patients with unilateral breast cancer for whom data were recorded in the Surveillance, Epidemiology, and End Results (SEER) registry. More than half (57.8%) chose breastconserving surgery, which also became more common during the study period. Another 38.9% (59,460 women) chose unilateral mastectomy, and 3.3% (4,969 women) had bilateral mastectomy. Connecticut had the lowest rate of contralateral prophylactic mastectomy (1.4%); metropolitan Atlanta and Iowa were both at the high end (5.6%). The study did not address BRCA1 or BRCA2 mutations, two known risk factors that lead some women with family histories of breast cancer to choose double mastectomy as a precaution while they are still cancer-free. Dr. Tuttle, an ACS Fellow, said he did not believe these mutations were common in the study population. Also unexplored were the long-term clinical outcomes. Survival data are not mature, Dr. Tuttle said, but most previous studies have not shown a benefit. Women with unilateral breast cancer are at greater risk of their primary disease spreading than of developing a second cancer in the other breast. The investigators did find that among women undergoing mastectomy, those with favorable prognostic factors such as smaller tumor size, negative lymph nodes, and lower tumor grade were more likely to choose double mastectomy. These patients were more likely to benefit, the researchers speculated, because they would live longer and therefore have more time to be at risk for contralateral breast cancer. Dr. Tuttle said improvements in surgery and in breast reconstruction techniques may have made double mastectomy more acceptable to some women, but he believes emotion drives many of the decisions. Often surgery follows diagnosis by a week or 2, he noted. “It is one of the most emotional times in women’s lives when they are diagnosed with breast cancer, and they can make these irreversible decisions,” he said, adding, “A lot of women tell me, ‘I just want to be done with it.’ ” Physicians need to be aware of this phe- nomenon and encourage women to wait before electing contralateral prophylactic mastectomy, he said. A second surgery can still be done a year or 2 later. Dr. Julie R. Gralow, an American Society of Clinical Oncology breast cancer expert, agreed in an interview that finding out why women are making this decision is a critical next step. Dr. Gralow, a medical oncologist at the University of Washington in Seattle, was initially surprised by Dr. Tuttle’s findings but remarked that more women also had been asking for bilateral mastectomy in her own practice. In most cases, she said, they were satisfied with their decision when seen some time afterward, but not always. “At our site, when a woman brings this up, we tell her we will support her, but we want her to take time to think about it,” Dr. Gralow said. Physicians need to be sure the patient is not making the decision out of panic and that she understands bilateral mastectomy does not improve survival, Dr. Gralow advised. Dr. Tuttle and his colleagues have commenced a second study analyzing how women decide to have both breasts removed. “It will be interesting to see how much of a role a surgeon has in this,” he said. “Is there a difference with the gender of the surgeon?” ■ CLASSIFIEDS CONTINUING EDUCATION WWW.COSMETICPHYSICIANS.ORG Cosmetic Procedures • Botox, Restylane & Other Cosmetic Fillers • Laser & Intense Pulsed Light Treatments for Hair Removal, Facial Veins, Rosacea, Pigmented Lesions, Acne, Tissue Tightening • Chemical Peels • Microdermabrasion & Cosmeceuticals • Leg Vein Treatment (Sclerotherapy) • Body Contouring , Mesotherapy, Liposuction (Overview) American Academy of Cosmetic Physicians Cosmetic Workshops & Individual Training A National Program to Train Physicians in Cosmetic Procedures Individual (one-on-one) training is available from faculty members 2008 UPCOMING COURSES: AWAKE Liposuction Jan 11-12 Jan 19-20 Jan 25-26 Feb 1-2 Feb 9-10 Feb 23-24 Mar 1-2 Mar 7-8 Los Angeles, CA West Palm Beach, FL Dallas, TX Los Angeles, CA New York, NY Scottsdale, AZ Dallas, TX New York, NY AWAKE Liposuction Performed under local tumescent anesthesia, patient is AWAKE throughout the procedure. • History of Liposuction • Proper Patient Selection & Management • Pre-Op & Post-Op Photography & Patient Marking • Room Setup • Liposuction Techniques • Hands on Training of Infiltration & Liposuction • Marketing & Business Model • Malpractice Insurance • Patient Safety All Courses are AMA PRA CATEGORY 1 CME Cosmetic Procedures Jan 24-25 Jan 25 Mar 12-14 Jan 18-19 Feb 8-9 Mar 7-8 Vancouver, BC, Canada Scottsdale, AZ Vancouver, BC, Canada Los Angeles, CA Los Angeles, CA Los Angeles, CA AWAKE Breast Augmentation Performed under local tumescent anesthesia, patient is AWAKE throughout the procedure. • Proper Patient Selection & Patient Management • Pre-Op & Post-Op Photography • Room & Equipment Setup • AWAKE Breast Augmentation Techniques & Methods • Hands-on Training of Infiltration & Augmentation • Malpractice Insurance • Patient Safety & Complications AWAKE Breast Augmentation FACULTY: Robert L. 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