Surgery News - March 2009 - (Page 14) 14 BREAST, SKIN & SOFT TISSUE MARCH 2009 • SURGERY NEWS Contralateral Prophylactic Mastectomy Rate Doubles If the trend continues, ‘we may have a problem with access to reconstruction,’ an expert cautions. BY BRUCE JANCIN Else vier Global Medical Ne ws S A N A N T O N I O — The recent marked increase in contralateral prophylactic mastectomies—most of them unnecessary—is a trend that could bring adverse consequences for overall breast cancer care, a prominent surgeon cautioned at the San Antonio Breast Cancer Symposium. “In the time it takes a surgeon to perform a bilateral skin-sparing mastectomy with immediate reconstruction, a surgeon can probably do about three breastsparing surgical procedures. As a result, I worry that with increasing demands on the breast surgeons’ time, there are going to be potential delays for many patients in the time from diagnosis of cancer to ultimate surgical treatment,” said Dr. Todd M. Tuttle, chief of surgical oncology at the University of Minnesota, Minneapolis. “If these trends continue we may have a problem with access to reconstruction; we already have a shortage of breast reconstructive surgeons in the U.S.,” he noted. Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results registry, Dr. Tuttle and his coworkers have shown that the annual rate of contralateral prophylactic mastectomy (CPM) in women with unilateral invasive breast cancer more than doubled from 1998 to 2003 ( J. Clin. Oncol. 2007;25:5203-9). He estimated that at least 10,000 women per year now undergo CPM. In a separate study soon to be published in the Journal of Clinical Oncology, Dr. Tuttle and his coinvestigators showed that the trend for a recent steep rise in CPM also applies to women with ductal carcinoma in situ. Among 51,229 patients diagnosed with DCIS in the SEER database for 1998-2005, there were 2,082 CPMs. The CPM rate for these patients climbed by 147% during the study period. Unlike the case for some other operations, there were no broad regional trends in CPM rates in women with invasive breast cancer. Among the highest rates in 2003 were those in metropolitan Atlanta (13.5%), Iowa (10.5%), and California (9.6%). Rates were lowest in Utah (3.7%), Connecticut (4.7%), and Hawaii (4.8%), according to Dr. Tuttle. The best estimate is that CPM reduces the risk of contralateral breast cancer by 95%-97%. But Dr. Tuttle considers most CPM unnecessary because there is no evidence that the surgery improves overall survival. For most patients, the risk of systemic metastases from their known breast cancer far exceeds the risk of de- veloping metachronous contralateral breast cancer, which remains constant at about 0.7% per year in women with unilateral invasive breast cancer and 0.5% per year in those with DCIS. Moreover, CPM is irreversible and not risk free. In a series of 239 patients who underwent CPM, most with immediate reconstruction, at M.D. Anderson Cancer Center, Houston, the overall complication rate was 16.3%, with about half of the complications occurring in the contralateral breast (Cancer 2004;101: 1977-86). For most patients—those not at high genetic risk—surveillance and adjuvant endocrine therapy are a good alternative to CPM, the surgeon continued. A U.K. physician in the audience said he believes there has been a sea change in the attitude of British patients toward CPM. Back when the major clinical trials of breast-conserving therapy were being done, there was strong, widespread opposition to mastectomy. Now more and more patients embrace it for the peace of mind they anticipate. Is the same thing happening in the United States? he asked. “I do think there has been a shift toward being more aggressive, and I think it’s largely been driven by patients,” Dr. Tuttle replied. “In talking to my plastic surgery colleagues, they tell me that the most important aspect of breast reconstruction is symmetry, and I think many women view bilateral mastectomy with or without reconstruction as being able to effectively achieve symmetry.” When should a physician initiate discussion of CPM for a clinically normal breast? Dr. Tuttle doesn’t do so in average-risk patients who are good candidates for breast-conserving surgery. He does bring up CPM selectively in average-risk women who want a mastectomy and are obese or have extremely large breasts, for it may be difficult to achieve symmetry in such patients. He routinely initiates discussion of CPM in women at high risk for contralateral breast cancer because of a BRCA mutation or a history of radiotherapy to the chest earlier in life. But he actively dissuades women with advanced-stage breast cancer from undergoing CPM because their risk of systemic metastases from their known cancer vastly exceeds their risk of contralateral breast cancer. “I think the major challenge surgeons face is in dealing with the patient who’s at average risk of developing contralateral breast cancer and wants to have CPM. I have no data to support my opinion, but I believe that most women grossly overestimate their risk of developing contralateral breast cancer. So I spend some time telling them about what the risk really is, I talk about the side effects of CPM, and I talk about the surveillance options. “Usually after a 30-minute discussion, the patient thanks me for my advice and asks when we can schedule the CPM with immediate reconstruction,” Dr. Tuttle said. CLASSIFIEDS A l s o a v a i l a b l e a t w w w. e l s e v i e r h e a l t h c a r e e r s . c o m PROFESSIONAL OPPORTUNITIES ONE SPECTACULAR VENUE! 8, 2009 April 5- alace P Caesars a , Nevad s Vegas La THREE CUTTING EDGE CONFERENCES Hospital employed general surgery position in dynamic family oriented community 30 minutes to downtown Pittsburgh associated with a modern and financially stable 238 bed hospital. 1-3 call. Excellent salary, bonus and benefit package. 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