Rising rates of bilateral mastectomy with reconstruction following neoadjuvant chemotherapy

Abstract

Neoadjuvant chemotherapy is used to allow more limited breast surgery without compromising local control. We sought to evaluate nationwide surgical trends in patients with operable breast cancer treated with neoadjuvant chemotherapy and factors associated with surgical type. We used the National Cancer Database to identify 235,339 women with unilateral T1–3N0–3M0 breast cancer diagnosed between 2010 and 2014, and treated with surgery and chemotherapy. Of these, 59,568 patients (25.3%) were treated with neoadjuvant chemotherapy. Rates of pathologic complete response to neoadjuvant chemotherapy increased from 33.3% at the start of the study period in 2010 to 46.3% at the end of the period in 2014 (p=0.02). Rates of breast- conserving surgery changed little, from 37.0% to 40.8% (p=0.22). While rates of unilateral mastectomy decreased from 43.3% to 34.7% (p=0.02) and rates of bilateral mastectomy without immediate reconstruction remained similar (11.7% to 11.5%, p=0.82), rates of bilateral mastectomy with immediate reconstruction rose from 8.0% to 13.1% (p=0.02). Patients who were younger, with private/managed care insurance, and diagnosed in more recent years were more likely to achieve pathologic complete response; however, these same characteristics were associated with receipt of bilateral mastectomy (versus breast-conserving surgery). Additionally, non-Hispanic white race and higher area education attainment were both associated with bilateral mastectomy. These findings did not differ by age or molecular subtype. Further study of non-clinical factors that influence selection of more extensive surgery despite excellent response to neoadjuvant chemotherapy is warranted.

Bilateral immediate two-stage breast reconstruction in patients with unilateral breast cancer: Outcomes analysis and risk assessment

“…The rate of contralateral prophylactic mastectomy has more than doubled in the past decades, with a similar trend in immediate reconstruction. [1][2][3][4][5][6][7] Patients with no proven genetic predisposition also opt for this elective operation likely due to cancer-related anxiety, despite the lack of evidence for a survival benefit. 1 , 8 , 11 , 21-23 The availability of reconstruction appears to influence patient decision-making 6 , 7 , 12 , 15 , 24 , 25 , and there is evidence of higher patient satisfaction and superior long-term cosmetic outcome with bilateral implantbased reconstruction.…”

“…Patients with unilateral diagnosis of breast cancer increasingly elect to undergo bilateral mastectomies. [1][2][3][4][5][6][7] Even though the risk of contralateral breast cancer is low in the absence of a genetic mutation, patient misperceptions of the true benefits of a contralateral prophylactic mastectomy might account for this increase. 1 , 8 , 9 Young patient age, Caucasian ethnicity, higher education level, family history, and positive genetic testing have been shown to be predictors of prophylactic surgery.…”

Trends in bilateral mastectomy for cases of unilateral breast cancer in a Brazilian institute over a 10-year period

“…A recent NCDB-based study reported similar results following the evaluation of almost 60,000 women submitted to NACT between 2010 and 2014. 24 Despite the increase in full pathological response over the time period, the rates of breast conservation increased slightly from 37.0% to 40.8% (p = 0.22) and bilateral mastectomy rates with immediate breast reconstruction increased from 8% to 13.1%, with a reduction in unilateral mastectomy. In the present study, bilateral surgery increased for patients with aggressive chemosensitive disease (70% of HER2 and 67% of the TN cases), although they would normally be potential candidates for NACT and conservative surgeries.…”

Using the modified frailty index to predict negative outcomes in free‐flap breast reconstruction: A National Surgical Quality Improvement Project‐based study

“…With the rates of mastectomy for both oncologic and prophylactic needs rising (Pollom et al, 2018), breast reconstruction remains a bedrock procedure for plastic surgeons. Given the improved aesthetic outcomes and satisfaction rates, patients are consistently opting to undergo free flap breast reconstruction rather than implant-based reconstruction, if they are a candidate (Pirro et al, 2017).…”