NEW YORK (Reuters Health) - Women undergoing contralateral prophylactic mastectomy (CPM) and reconstruction have more post-op complications than those who choose unilateral surgery, but they also report more satisfaction with their new breasts, new research reports.
"The level of interest in CPM in our patient population continues to grow and physicians are often faced with the challenge of guiding patients through these difficult decisions," said lead author Dr. Adeyiza O. Momoh of the University of Michigan Health System in Ann Arbor.
"These findings provide more objective information about the complications and quality of life after mastectomy and reconstruction that doctors can share with their patients, who can then make educated decisions in favor of unilateral mastectomy or CPM," he told Reuters Health by email.
As part of the five-year prospective multicenter Mastectomy Reconstruction Outcomes Consortium study, Dr. Momoh and his colleagues recruited women having mastectomy and breast reconstruction for unilateral breast cancer at 11 medical centers in the U.S. and Canada. They compared patients who chose to have CPM with those who decided against it.
Women 18 and above undergoing first-time, immediate postmastectomy breast reconstruction for unilateral carcinoma in situ or cancer treatment were eligible to participate. Those who underwent bilateral mastectomy had no genetic, pathologic, or radiographic abnormalities but had the contralateral breast removed prophylactically.
Patients who had stage 4 metastatic breast cancer, prior mastectomy, bilateral reconstruction with two different methods, or who did not adequately complete patient-reported outcome questionnaires about demographics, quality of life and treatment satisfaction, were excluded.
The researchers evaluated 540 women who underwent unilateral and 604 who underwent bilateral mastectomy with reconstruction. Participants completed questionnaires before surgery and one week, three months, one year, and two years after reconstruction.
Women who chose CPM were more likely to be younger, white, college graduates, and earn higher incomes than those who chose unilateral mastectomy (p<0 .05="" 28.="" annals="" in="" june="" of="" online="" p="" reports="" surgery="" team="" the="">
Bilateral implant reconstructions were associated with more complications (25.7% vs. 18.4%, p=0.013) and more major complications (17.2% vs. 11.3%, p=0.027) compared with unilateral implant procedures.
Bilateral autologous reconstructions were also associated with more complications than unilateral autologous reconstructions (55.7% vs. 42.6%, p=0.023); the major complication rate was higher, too, though not significantly so (39.3% vs. 30.5%, p=0.10).
Controlling for demographic and clinical covariates, bilateral autologous (odds ratio, 1.81; p=0.02) and bilateral implant reconstructions (OR, 1.76; p=0.003) were independently associated with a higher risk of complications than unilateral reconstructions.
However, at one year post-op, women who chose CPM with implant reconstructions were more satisfied with their breasts than women who had unilateral reconstructions (p=0.0009). There was no significant difference between the groups with autologous reconstructions, however.
While baseline anxiety was significantly greater in women choosing bilateral compared with unilateral implant reconstructions, there was no such difference with autologous reconstructions. By one year, anxiety levels were not significantly different between the groups.
Dr. Courtney Anne Vito from the division of surgical oncology at City of Hope in Duarte, California, said, "This study nicely highlights the strong psychosocial components of this decision. I don't think the study merits CPM being applied more broadly, but I do think it merits the informed-consent discussion that as surgeons we all have. Patient-centered decision-making is very important in this process."
"The authors nicely showed that patients who chose bilateral mastectomy had higher anxiety levels than those who had a single mastectomy performed," said Dr. Vito, who was not involved in the study.
But Dr. Vito cautioned, "Many scientific studies have shown no benefit to improved overall survival from cancer by removing the opposite breast, except in certain situations, such as strong family history, genetic mutation, etc., and it remains a controversial procedure because it's fraught with complications and it does not have proven medical benefits, from an oncologic standpoint."
"The complication rate was 55%, even among women having bilateral mastectomy and autologous flap transplantation of tissue from the abdomen to re-create the breast, which garnered the highest satisfaction levels," she said. "So these patients were more likely than not to have a major or minor complication such as hemorrhage; seroma; dehiscence; infection; necrosis; scarring; or implant malposition, leakage or rupture. And they were at higher risk of having a surgical complication than of having a second breast cancer."
SOURCE: http://bit.ly/2a0SAZJ
Ann Surg 2016.
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