Contralateral Breast Cancer and Risk Reducing Mastectomy

• In the last 10 years:
  • There has been a significant focus on the role of contralateral prophylactic mastectomy and the risk of contralateral breast cancer
• Single-institution studies and Surveillance, Epidemiology, and End Results program (SEER) data:
  • Have found contralateral prophylactic mastectomy rates:
    • To be as high as 25%, which continue to increase
    • Further, this trend seems to be limited to the United States
• Nichols et al. reviewed rates of contralateral breast cancer between 1976 and 2006 using the SEER database:
  • Overall, they found the rate of contralateral breast cancer:
    • To be declining approximately 3% per year since 1985
  • From 1990 forward:
    • They found this benefit to be restricted to those presenting with an ER+ breast cancer:
      • With annual incidence rates of contralateral breast cancer of 0.25% to 0.37% when the index cancer was diagnosed after age 30 years
    • The rates of contralateral breast cancer were higher in patients with ER negative breast cancers:
      • But still remained reasonably low with annual incidence rates of contralateral breast cancer of 0.45% to 0.65% when the index cancer was diagnosed after age 40 years
• The use of adjuvant endocrine therapy has contributed to this decline in contralateral breast cancer rates:
  • As it reduces the risk of contralateral breast cancer by approximately 50%
• Contralateral prophylactic mastectomy:
  • Is attributed with approximately a 90% to 94% overall reduction in the risk of contralateral breast cancer, not 100%
• Contralateral prophylactic mastectomy:
  • Does not improve overall survival
  • Recent modeling suggests the added absolute benefit of contralateral prophylactic mastectomy to overall survival is less than 1.45%
• The American Society of Breast Surgeons published a consensus statement with indications and suggestions for patient management and decision making with regard to contralateral prophylactic mastectomy:
  • Discouraging the procedure for women with unilateral breast cancer at average risk for contralateral cancer
• References
• Nichols HB, Berrington de Gonzalez A, Lacey JV, Rosenberg PS, Anderson WF. Declining incidence of contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol. 2011;29(12):1564-1569.
• Early Breast Cancer Trialists’ Collaborative Group, Davies C, Godwin J, et al. Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials. Lancet. 2011;378(9793):771-784.
• King TA, Sakr R, Patil S, et al. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol. 2011;29(16):2158-2164.
• Metcalfe K, Lynch HT, Ghadirian P, et al. Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. J Clin Oncol. 2004;22(12):2328-2335.
• Portschy PR, Kuntz KM, Tuttle TM. Survival outcomes after contralateral prophylactic mastectomy: a decision analysis. J Natl Cancer Inst. 2014;106(8).
• Boughey JC, Attai DJ, Chen SL, et. al.. Contralateral prophylactic mastectomy consensus statement from the American Society of Breast Surgeons: additional considerations and a framework for shared decision making. Ann Surg Oncol. 2016 Oct;23(10):3106-3111.

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