Contralateral Prophylactic Mastectomy in Women with Unilateral Breast Cancer Who Are Genetic Carriers, Have a Strong Family History or Are just Young at Presentation

Abstract

The uptake of contralateral prophylactic mastectomy is rising with increasing trends that are possibly highest in the USA. Whilst its role is generally accepted in carriers of recognized high-risk predisposition genes such as BRCA1 and BRCA2 when the affected individual is premenopausal, controversy surrounds the benefit in less understood risk-profile clinical scenarios. This comprehensive review explores the current evidence underpinning the role of contralateral prophylactic mastectomy and its impact on contralateral breast cancer risk and survival in three distinct at-risk groups affected by unilateral breast cancer: known genetic carriers, those with strong familial risk but no demonstrable genetic mutation and women who are of young age at presentation. The review supports the role of contralateral prophylactic mastectomy in “high risk” groups where the evidence suggests a reduction in contralateral breast cancer risk. However, this benefit is less evident in women who are just young at presentation or those who have strong family history but no demonstrable genetic mutation. A multidisciplinary and personalized approach to support individuals in a shared-decision making process is recommended.

Clinicopathologic Profile of Breast Cancer in Germline ATM and CHEK2 Mutation Carriers

“…In our cohort, interestingly, all patients underwent genetic testing after breast surgery: this could have determined the high rate of contralateral BC since none of these women underwent risk-reducing contralateral mastectomy. Although the evidence on whether contralateral prophylactic mastectomy improves survival for BRCA carriers with BC is conflicting, this procedure reduces the risk of contralateral tumor by 93% [ 52 ]. As a result, several international guidelines include this option [ 10 , 53 ].…”

Management of patients with BRCA mutation from the point of view of a breast surgeon

“…In addition there are more re-do surgeries and more complications compared to breast conserving therapy on the affected side [ 183 ]. The higher risk of contralateral breast cancer in female with BRCA mutation justifies the choice of contralateral RRM in these patients, but the same benefit is less evident in those without mutations, even though there is a strong family history [ 184 ].…”

Breast Cancer Adjuvant Radiotherapy in BRCA1/2, TP53, ATM Genes Mutations: Are There Solved Issues?

“…However, as noted by Theoh et al, the choice of a risk-reducing bilateral prophylactic mastectomy should be carefully taken into account due to the risk of a new homolateral and contralateral BC, especially in younger patients. 105 Mutations in TP53 are considered an absolute contraindication of radiotherapy except in those with a significantly very high risk of locoregional recurrence; mastectomy is increasingly advised. 53 Radiotherapy may also be considered with caution in cases of ATM mutations, mainly in case of deleterious heterozygosity alone or in combination with ATM mutations in younger patients.…”