Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Ann Surg Oncol. 2020 Mar;27(3):743-749. doi: 10.1245/s10434-019-08038-8. Epub 2019 Nov 15.
Neoadjuvant chemotherapy (NAC) for breast cancer increases breast-conserving surgery (BCS) rates, but many women opt for mastectomy with contralateral prophylactic mastectomy (CPM). Here we evaluate factors associated with CPM use in women undergoing mastectomy post-NAC.
A retrospective institutional NAC database review identified women with clinical stage I-III, unilateral invasive breast cancer undergoing unilateral mastectomy (UM) or CPM mastectomy from 9/2013 to 12/2017. Clinical/pathologic characteristics, imaging, and presence of contraindications to BCS post-NAC were compared, with subset analysis of BCS candidates. The multivariable analysis was adjusted for potential confounders.
Five hundred sixty-nine women underwent mastectomy after NAC, 297 (52%) UM and 272 (48%) CPM. On univariable analysis, younger age, BRCA+, lower pre-NAC clinical stage, pathologic complete response, and axillary surgery extent were associated with CPM (all p < 0.01). Favorable post-NAC clinical factors of no residual palpable disease, clinically negative nodes, complete response on breast imaging, and no post-NAC contraindication to BCS were also associated with CPM (all p < 0.01). On multivariable analysis, young age (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.91-0.95), lower pre-NAC stage (OR 0.51, 95% CI 0.34-0.77), and no contraindication to BCS (OR 3.12, 95% CI 2.02-4.82) were significantly associated with CPM. Among the 203 (35%) women who had no contraindications to BCS post-NAC, 145 (71%) underwent CPM. BRCA+ and family history were reasons more frequently cited for mastectomy among CPM than UM (p < 0.001).
CPM was performed in 48% of women undergoing mastectomy after NAC; younger women with earlier-stage cancers were more likely to undergo CPM. While increased use of CPM in women with more favorable disease is medically appropriate, our findings indicate a lost opportunity for use of BCS.
新辅助化疗（NAC）可提高乳腺癌保乳手术（BCS）的比例，但许多女性选择在接受 NAC 后行乳房切除术并同时进行对侧预防性乳房切除术（CPM）。本研究旨在评估与接受 NAC 后行乳房切除术的女性中 CPM 应用相关的因素。
对 2013 年 9 月至 2017 年 12 月间在我院接受单侧乳房切除术（UM）或 CPM 乳房切除术的 I-III 期单侧浸润性乳腺癌患者的回顾性机构 NAC 数据库进行了分析。比较了临床/病理特征、影像学表现以及 NAC 后行 BCS 的禁忌证，对 BCS 候选者进行了亚组分析。多变量分析调整了潜在混杂因素。
569 例患者在接受 NAC 后行乳房切除术，其中 297 例（52%）行 UM，272 例（48%）行 CPM。单变量分析显示，年龄较小、BRCA+、术前 NAC 临床分期较低、病理完全缓解和腋窝手术范围与 CPM 相关（均 p<0.01）。NAC 后无残留可触及疾病、临床阴性淋巴结、乳腺影像学完全缓解和无 NAC 后 BCS 禁忌证等有利的临床因素也与 CPM 相关（均 p<0.01）。多变量分析显示，年轻（比值比 [OR] 0.93，95%置信区间 [CI] 0.91-0.95）、术前 NAC 分期较低（OR 0.51，95% CI 0.34-0.77）和无 BCS 禁忌证（OR 3.12，95% CI 2.02-4.82）与 CPM 显著相关。在 203 例（35%）无 NAC 后 BCS 禁忌证的患者中，145 例（71%）行 CPM。与 UM 相比，CPM 中 BRCA+和家族史更常被认为是行乳房切除术的原因（p<0.001）。
在接受 NAC 后行乳房切除术的患者中，有 48%的患者行 CPM；年轻、癌症分期较早的女性更可能行 CPM。虽然在疾病更有利的女性中更常使用 CPM 是合理的，但我们的研究结果表明，BCS 的应用机会被错失。
