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Official reprint from UpToDate www.uptodate.com ©2015 UpToDate Author Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C) Section Editor Russell S Berman, MD Deputy Editor Don S Dizon, MD, FACP Contralateral prophylactic mastectomy All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2015. | This topic last updated: Dec 03, 2014. INTRODUCTION — A contralateral prophylactic mastectomy (CPM) is a risk reducing mastectomy performed in the clinical setting for the patient diagnosed with an invasive or a noninvasive breast cancer. While there is no clear survival benefit for most breast cancer patients who do not carry a deleterious BRCA1 or BRCA2 mutation [13 ], the rates of performing a CPM have increased over the last several years [4,5 ]. The risk of a contralateral breast cancer, the decision making process to undergo a CPM, and outcomes will be reviewed in this topic. Management of patients with invasive and noninvasive breast cancer, with and without an inherited genetic mutation, is reviewed separately and includes: RISK OF CONTRALATERAL BREAST CANCER — Patients with a unilateral sporadic breast cancer are at a modest risk of developing a contralateral breast cancer (CBC), and most women never will develop a contralateral second primary breast cancer [6,7 ]. For patients who present with unilateral breast cancer, the risk of developing a contralateral breast cancer is estimated to be 0.5 to 1.0 percent/year cumulative over their lifetime [8,9 ]. However, a review of 162 patients with sporadic breast cancer found that the 10year cumulative incidence of contralateral breast was 1 percent [10 ]. (See "Patterns of relapse and longterm complications of therapy in breast cancer survivors" .) For patients who carry a deleterious BRCA1 or BRCA2 mutation, the risk of a contralateral breast cancer is approximately 10 to 25 percent [10,11 ]. However, some studies have estimated the risk to be as high as 65 percent for BRCA1 carriers and 50 percent for BRCA2 carriers [12 ]. (See "Management of hereditary breast and ovarian cancer syndrome patients with BRCA mutations", section on 'Treatment and prognosis of women who develop breast cancer' .) CONTRALATERAL PROPHYLACTIC MASTECTOMY RISK REDUCTION — Based upon a prospective study of 745 women with breast cancer and a family history of breast and/or ovarian cancer undergoing a CPM, the risk reduction of a contralateral breast cancer (CBC) was approximately 96 percent [6 ]. In this cohort, the risk reduction following a CPM for women less than age 50 years (n = 388) was 94.4 percent and 96.0 percent for women 50 years of age and older. DECISION MAKING PROCESS — The decision to undergo a contralateral prophylactic mastectomy (CPM) is frequently an individual choice and generally based upon personal preference and management (eg, mastectomy) of the presenting breast cancer. In addition, many women overestimate their actual risk for cancer in the unaffected breast. Other influences, including the surgeon, primary care physician, friends, and/or family members are often cited as suggesting a CPM. Hence, the patient and her surgeon should fully discuss the actual risks of a contralateral breast cancer in terms of the patient’s own personal and family history and her goals for treatment. ® ® (See "Overview of the treatment of newly diagnosed, nonmetastatic breast cancer" .) (See "Ductal carcinoma in situ: Treatment and prognosis" .) (See "Treatment protocols for breast cancer" .) (See "BRCA1 and BRCA2: Prevalence and risks for breast and ovarian cancer" .) (See "Management of hereditary breast and ovarian cancer syndrome patients with BRCA mutations" .)

Contralateral Prophylactic Mastectomy

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  • 5/16/2015 Contralateralprophylacticmastectomy

    http://www.uptodate.com/contents/contralateralprophylacticmastectomy?topicKey=ONC%2F94744&elapsedTimeMs=0&source=search_result&searchTerm 1/7

    OfficialreprintfromUpToDate www.uptodate.com2015UpToDate

    AuthorAneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)

    SectionEditorRussellSBerman,MD

    DeputyEditorDonSDizon,MD,FACP

    Contralateralprophylacticmastectomy

    Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.Literaturereviewcurrentthrough:Apr2015.|Thistopiclastupdated:Dec03,2014.

    INTRODUCTIONAcontralateralprophylacticmastectomy(CPM)isariskreducingmastectomyperformedintheclinicalsettingforthepatientdiagnosedwithaninvasiveoranoninvasivebreastcancer.WhilethereisnoclearsurvivalbenefitformostbreastcancerpatientswhodonotcarryadeleteriousBRCA1orBRCA2mutation[13],theratesofperformingaCPMhaveincreasedoverthelastseveralyears[4,5].

    Theriskofacontralateralbreastcancer,thedecisionmakingprocesstoundergoaCPM,andoutcomeswillbereviewedinthistopic.Managementofpatientswithinvasiveandnoninvasivebreastcancer,withandwithoutaninheritedgeneticmutation,isreviewedseparatelyandincludes:

    RISKOFCONTRALATERALBREASTCANCERPatientswithaunilateralsporadicbreastcancerareatamodestriskofdevelopingacontralateralbreastcancer(CBC),andmostwomenneverwilldevelopacontralateralsecondprimarybreastcancer[6,7].Forpatientswhopresentwithunilateralbreastcancer,theriskofdevelopingacontralateralbreastcancerisestimatedtobe0.5to1.0percent/yearcumulativeovertheirlifetime[8,9].However,areviewof162patientswithsporadicbreastcancerfoundthatthe10yearcumulativeincidenceofcontralateralbreastwas1percent[10].(See"Patternsofrelapseandlongtermcomplicationsoftherapyinbreastcancersurvivors".)

    ForpatientswhocarryadeleteriousBRCA1orBRCA2mutation,theriskofacontralateralbreastcancerisapproximately10to25percent[10,11].However,somestudieshaveestimatedtherisktobeashighas65percentforBRCA1carriersand50percentforBRCA2carriers[12].(See"ManagementofhereditarybreastandovariancancersyndromepatientswithBRCAmutations",sectionon'Treatmentandprognosisofwomenwhodevelopbreastcancer'.)

    CONTRALATERALPROPHYLACTICMASTECTOMYRISKREDUCTIONBaseduponaprospectivestudyof745womenwithbreastcancerandafamilyhistoryofbreastand/orovariancancerundergoingaCPM,theriskreductionofacontralateralbreastcancer(CBC)wasapproximately96percent[6].Inthiscohort,theriskreductionfollowingaCPMforwomenlessthanage50years(n=388)was94.4percentand96.0percentforwomen50yearsofageandolder.

    DECISIONMAKINGPROCESSThedecisiontoundergoacontralateralprophylacticmastectomy(CPM)isfrequentlyanindividualchoiceandgenerallybaseduponpersonalpreferenceandmanagement(eg,mastectomy)ofthepresentingbreastcancer.Inaddition,manywomenoverestimatetheiractualriskforcancerintheunaffectedbreast.Otherinfluences,includingthesurgeon,primarycarephysician,friends,and/orfamilymembersareoftencitedassuggestingaCPM.Hence,thepatientandhersurgeonshouldfullydiscusstheactualrisksofacontralateralbreastcancerintermsofthepatientsownpersonalandfamilyhistoryandhergoalsfortreatment.

    (See"Overviewofthetreatmentofnewlydiagnosed,nonmetastaticbreastcancer".)

    (See"Ductalcarcinomainsitu:Treatmentandprognosis".)

    (See"Treatmentprotocolsforbreastcancer".)

    (See"BRCA1andBRCA2:Prevalenceandrisksforbreastandovariancancer".)

    (See"ManagementofhereditarybreastandovariancancersyndromepatientswithBRCAmutations".)

  • 5/16/2015 Contralateralprophylacticmastectomy

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    PatientsmustbemadeawareoftherisksandcomplicationsofundergoingaCPM,asthisinvolvesamoreextensiveoperation(bilateralmastectomieswithorwithoutbilateralreconstruction),andthatwhileriskofcontralateralbreastcancerisreduced[2,20],thedataregardingsurvivalbenefitsaremixed.(See'Outcomes'below.)

    POSTOPERATIVEMORTALITYANDMORBIDITYMortalityratesareuniformlylow(

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    OUTCOMES

    OverallsurvivalThereisnoclearoverallsurvivalbenefitformostbreastcancerpatientswhoundergoacontralateralprophylacticmastectomy(CPM),andnorandomizedtrialshaveyetbeenperformed.However,forpatientswithadeleteriousBRCA1orBRCA2mutation,andinsomestudies,womendiagnosedatayoungage(

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    beapproximately1to2percent[27,28].

    Psychosocialeffects

    Bodyimage,femininityAdversechangesinbodyimageincludingdiminishedfeelingsoffemininity,sexualityandsexualsatisfaction,andselfesteemcanoccurfollowingaCPM[6,2932].Negativebodyimagewasalsoassociatedwithhighpreoperativecancerdistress[29].Inasurveyofwomenwhohadundergonecontralateralprophylacticmastectomy,42percentstatedthattheirsenseofsexualitywasworsethanexpected,and31percentfeltthattheirselfconsciousnessabouttheirappearancewasalsoworsethanexpected[19].However,80percentreportedthattheywereextremelyconfidentintheirdecisiontohaveCPM,and90percentwouldhavemadethesamedecisionagain[19].

    ThepersonalsatisfactionfollowingaCPMisreportedlyhigh[32,33].Forexample,asurveyof583patientsfoundthatthemajority(83percent)ofwomenweresatisfiedwiththeCPM10yearsaftertheoperation,while8percentwereneutraland9percentweredissatisfied[32].However,33percentweredissatisfiedwithbodyappearance,26percenthadadversefeelingsoffemininity,and23percentreportedadversesexualrelationships.

    However,suchahighlevelofsatisfactionmaybesecondarytocognitivedissonance,aphenomenondocumentedininvalidatedpatientsatisfactionmeasurements,andrelevanttoautonomoussurgicaldecisionmakingwhenthedecisionisdifficulttochange[2,3436].

    QualityoflifeQualityofliferelatedmeasuresforwomenundergoingaCPMwerecomparabletowomeninthegeneralpopulation.Inaprospectivestudyof60womenwithbreastcancerwhohadalsoundergoneaCPM,mostpatientshadasatisfactoryhealthrelatedqualityoflifetwoyearsaftertheoperation,withnodifferenceinanxietyordepression[31].

    OPERATIVEAPPROACHES

    MastectomywithorwithoutreconstructionTypically,mostpatientsareadvisedtoundergothesametypeofmastectomy(eg,skinsparing,conventional)thatisusedforthemastectomytotreatthebreastcancer.Thetypeofmastectomyisdeterminedbythetumorcharacteristics,patientbodyhabitus,patientpreference,andsurgicalexpertise.Thereisnoadverseimpactofimmediatereconstructioneitherinthedevelopmentordetectionoffuturecancers[37].Reconstructionisdeterminedbytheuseofpostoperativeradiationtreatments,patientpreference,andsurgeonexpertise.

    Specificapproachestoperformingamastectomyandbreastreconstructionarediscussedseparately.(See"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement"and"Breastreconstruction:Preoperativeassessment".)

    SentinellymphnodedissectionWhiletherearedifferencesofopinion,asentinelnodelymphnodedissectionisnotrequiredwhenperformingaCPM[27,28,38].Somehavearguedthattheriskofthisminimallyinvasiveprocedureissmall,andwouldpreempttheneedforaxillaryevaluationifanoccultinvasivecancerwasfoundonfinalpathology[38].Others,however,arguethattheriskoffindingmetastaticdiseasewarrantingaxillarystaginginpatientsundergoingprophylacticmastectomyislow,andthereforesentinelnodebiopsyinthesepatientscanbeomitted[27].Randomizedtrialshavenotbeenperformedtoresolvetheissue.(See"Diagnosis,stagingandtheroleofsentinellymphnodebiopsyinthenodalevaluationofbreastcancer"and"Sentinellymphnodebiopsyinbreastcancer:Techniques".)

    SUMMARYANDRECOMMENDATIONS

    Patientswithaunilateralsporadicbreastcancerareatamodestriskofdevelopinganinvasivecontralateralbreastcancer(CBC),andmostwomenneverwilldevelopacontralateralsecondprimarybreastcancer.(See'Riskofcontralateralbreastcancer'above.)

    ForbreastcancerpatientswhocarryaBRCA1orBRCA2mutation,theriskofacontralateralbreastcancerisestimatedtorangefrom10to65percent.(See'Riskofcontralateralbreastcancer'above.)

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    UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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    Womenwithbreastcancerandafamilyhistoryofbreastorovariancancerandwhoundergoacontralateralprophylacticmastectomy(CPM)havea96percentreductioninriskofdevelopingacontralateralcancer.(See'Contralateralprophylacticmastectomyriskreduction'above.)

    WomenwithbreastcancerundergoingaCPMhaveagreaterthantwofoldincreasedriskofmajorcomplications(eg,reoperation)comparedwithwomenundergoingaunilateralmastectomy.(See'Postoperativemortalityandmorbidity'above.)

    ACPMconfersanoverallsurvivalbenefitforwomenwhohavebreastcancerandcarryadeleteriousBRCA1orBRCA2mutation(see'Overallsurvival'above).Itislessclearifwomenwithsporadicbreastcancer,particularlywomenoverage50years,haveasurvivalbenefitwithaCPM.

    TheriskofidentifyinganoccultinvasivebreastcancerintheCPMspecimenisapproximately1to2percent.(See'Riskofidentifyinganoccultbreastcancer'above.)

    Typically,thesametypeofmastectomyisperformedforaCPMasforthemastectomytotreatthebreastcancer.(See'Mastectomywithorwithoutreconstruction'aboveand"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement".)

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    Disclosures:AneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)Nothingtodisclose.RussellSBerman,MDNothingtodisclose.DonSDizon,MD,FACPNothingtodisclose.Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.Conflictofinterestpolicy

    38. BurgerA,ThurtleD,OwenS,etal.Sentinellymphnodebiopsyforriskreducingmastectomy.BreastJ201319:529.

    Topic94744Version4.0

    Disclosures