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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".)



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

POSTOPERATIVEMORTALITYANDMORBIDITYMortalityratesareuniformlylow(



OUTCOMES

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



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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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.

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