Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN.
Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN.
Surgery. 2024 Mar;175(3):677-686. doi: 10.1016/j.surg.2023.09.015. Epub 2023 Oct 19.
In July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer. We incorporated these into practice with structured patient counseling and aimed to assess the effect of this initiative on contralateral prophylactic mastectomy rates.
We evaluated female patients with unilateral breast cancer undergoing mastectomy at our institution from January 2011 to November 2022. Variables associated with contralateral prophylactic mastectomy and trends over time were analyzed using the Wilcoxon rank sum test or χ analysis as appropriate.
Among 3,208 patients, (median age 54 years) 1,366 (43%) had a unilateral mastectomy, and 1,842 (57%) also had a concomitant contralateral prophylactic mastectomy. Across all patients, contralateral prophylactic mastectomy rates significantly decreased post-implementation from 2017 to 2019 (55%) vs 2015 to 2016 (62%) (P = .01) but increased from 2020 to 2022 (61%). Immediate breast reconstruction rate was 70% overall (81% with contralateral prophylactic mastectomy and 56% without contralateral prophylactic mastectomy, P < .001). Younger age, White race, mutation status, and earlier stage were also associated with contralateral prophylactic mastectomy. Genetic testing increased from 27% pre-guideline to 74% 2020 to 2022, as did the proportion of patients with a pathogenic variant (4% pre-guideline vs 11% from 2020-2022, P < .001), of whom 91% had a contralateral prophylactic mastectomy. Among tested patients without a pathogenic variant and patients not tested, contralateral prophylactic mastectomy rates declined from 78% to 67% and 48% to 38% pre -and post-guidelines, respectively, P < .001.
Implementation of specific patient counseling was effective in decreasing contralateral prophylactic mastectomy rates. While recognizing that patient choice plays a significant role in the decision for contralateral prophylactic mastectomy, further educational efforts are warranted to affect contralateral prophylactic mastectomy rates, particularly in the setting of negative genetic testing.
2016 年 7 月，美国乳腺外科学会发布指南，不建议单侧乳腺癌的平均风险女性行对侧预防性乳房切除术。我们将这些纳入了实践，进行了结构化的患者咨询，并旨在评估这一举措对预防性对侧乳房切除术率的影响。
我们评估了 2011 年 1 月至 2022 年 11 月在我院行单侧乳房切除术的女性患者。使用 Wilcoxon 秩和检验或 χ 分析（视情况而定）分析与预防性对侧乳房切除术相关的变量及其随时间的变化趋势。
在 3208 例患者中（中位年龄 54 岁），1366 例（43%）行单侧乳房切除术，1842 例（57%）同时行预防性对侧乳房切除术。在所有患者中，预防性对侧乳房切除术率在实施后从 2017 年至 2019 年显著降低（55%比 2015 年至 2016 年（62%）（P =.01），但从 2020 年至 2022 年增加（61%）。总体即刻乳房重建率为 70%（81%行预防性对侧乳房切除术，56%不行预防性对侧乳房切除术，P<.001）。年龄较轻、白人、突变状态和较早的分期也与预防性对侧乳房切除术有关。基因检测从指南前的 27%增加到 2020 年至 2022 年的 74%，有致病性变异的患者比例也从指南前的 4%增加到 2020 年至 2022 年的 11%（P<.001），其中 91%行预防性对侧乳房切除术。在无致病性变异的检测患者和未检测的患者中，预防性对侧乳房切除术率分别从指南前的 78%降至 67%和 48%降至 38%，P<.001。
实施特定的患者咨询对降低预防性对侧乳房切除术率有效。尽管认识到患者选择在预防性对侧乳房切除术的决策中起着重要作用，但仍需要进一步的教育努力来影响预防性对侧乳房切除术率，特别是在基因检测阴性的情况下。
