RISK REDUCING MASTECTOMY

MIR-5 Cirugía General y DigestivaHospital Universitario Reina Sofía, CórdobaRotación Externa. UMA-CHUAC.

Javier Cejas Arjona

Risk-reducing mastectomy in patients with no mutations carriers

Summary

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05

03

06. Conclutions

05. Guidelines

04. Predictors

03. Risk factor

02. Incidence

01. Key Concept

01. key concept

Key wordsCBC: Contralateral breast cancerCPM: Contralateral prophylactic mastectomy

Studies have demonstrate that CPM (Contralateral prophylactic mastectomy) effectively reduces the risk of contralateral breast cancer, with a relative risk reduction of approximately 90-96% in women with or without genetic predisposition

¿Prophylactic mastectomy or risk-reducing mastectomy?

Will I have better breast symmetry after CPM?

Can I avoid future screening with CPM?

Will CPM reduce the risk of contralateral breast cancer?

Will CPM reduces mortality risk?

Are you able to answer this questions from patients before the surgery?

02. Incidence

Incidence

CPM (Contralateral prophilactic mastectomy)

03. Risk factor

LEVEL I

Anti-endocrine treatment

DCIS

LEVEL II(Nichols, Lacey JCO 2011)

LEVEL II

RISK REDUCTIONTamoxifen 50%Aromatase inhibitor 70%

LEVEL IMetcalfe 2004 JCO; Evans 2013

LEVEL II(Reiner AS JCO-2013)

Bilateral desease (RR 3 .5)

First-degree relative (RR 1.5)

<55

(RR 2)

Lobulillar +FH

ER positive (RR1)ER negative (RR1.3)

ER status

<30 years 0.5-1.3% CBC rate

Age

0.6% annual CBC of DCIS and/or invasive carcinoma

First-degree relative (RR 2.5)

Risk factor CBC and level of evidence

<45

Family History

04. Predictors

Giardello et al: "Careful re-calibration is required before these models could be used in clinical decision-making"

predict-cbc

Manchester

CBCrisk

Calculate an individual’s risk of contralateral breast cancer in different ways using patient and tumor characteristics such as age at first primary breast cancer diagnosis, family history, ER status, breast density, first breast cancer type, and adjuvant treatments

Heterogeinity

Can we predict CBC?

05. Guidelines

Manchester Guidelines (UK)

ASBrS (USA)

NCCN (USA)

Five step process of pre-operative assessment and counseling:1.Reasons and clinical history2.Calculating CBC risk3.Giving the patient time for the desicision4.Multi-disciplinary team discussion5.Patient decision and consent form

Surgeons should make a direct recommendation for or against CPM to each patient

Patient counseling and informed discussion are important

Options of risk reduction should be discussed in a shared decision-making environment

CPM only recommended in high-risk situation, including BRCA 1/2 and strong family history

Patient counseling and informed discussion are important

Options of risk reduction should be discussed in a shared decision-making environment

Gail model used to identify non-mutation carriers at high risk

CPM only recommended in high-risk situation, including BRCA 1/2

40 years oldwhite race. No BRCA mutation,First menstruation at 12 years oldBiopsy atypical hyperplasia in the past with tumorectomy. Not DCISOne son at 31 years oldMother with BC at 50 years

She wants a CPM

What do you do??

Remedios

The Gile model

NCCN Guidelines "If a woman is not a mutation carrier or is ineligible for testing, a risk score is calculated using the Gail model incorporating other risk elements such as family history, atypical hyperplasia, and higher breast density. In women with a
1.7% 5-year risk of first primary breast cancer combined with a life expectancy of
10 years, CPM should be considered"

06. Conclutions

However risk of complication

No or little absolute risk reduction in low risk due to low incidence

Relative risk 90-96% reduced after CPM

90% satisfaction after CPM

NCCN guideline do not recommend screening after CPM

Patient-perceived risk overestimates calculated risk

No survival benefict after CPM compared to breast conserving

Will I have better breast symmetry after CPM?

Can I avoid future screening with CPM?

Will CPM reduce the risk of contralateral breast cancer?

Will CPM reduces mortality risk?

The decision to undergo CPM is preference-sensitive. Good decision-making requires the best available evidence about CPM combined with well-considered patient preferences

Patients rationals for CPM

Javier Cejas ArjonaMIR 5 Cirugía General y DigestivaHURS

Thank you very much!

Jolie effect