Tradeoffs Associated With Contralateral Prophylactic Mastectomy in Women Choosing Breast Reconstruction

Abstract

OBJECTIVE Assess postoperative morbidity and patient reported outcomes following unilateral and bilateral breast reconstruction in patients with unilateral breast cancer. BACKGROUND Relatively little is known about the morbidity associated with and changes in quality of life experienced by patients who undergo contralateral prophylactic mastectomy (CPM) and breast reconstruction. This information would be valuable for decision making in patients with unilateral breast cancer. METHODS Women undergoing mastectomy and breast reconstruction for unilateral breast cancer were recruited for this prospective observational study. Postoperative complications following implant and autologous breast reconstruction in patients undergoing unilateral or bilateral mastectomy were recorded. Preoperative and one year patient reported outcomes were measured. Univariate tests and logistic regression analyses were performed, studying the effects of reconstructive method, laterality, and risk factors on surgical complication rates, patient satisfaction and anxiety. RESULTS We identified 1144 women who underwent either unilateral (47.2%) or bilateral (52.8%) mastectomies with reconstruction. Bilateral autologous (OR 1.73, 95% CI 1.07–2.81) and implant reconstructions (OR 1.73, 95% CI 1.22–2.47) were associated with a higher risk of complications compared to unilateral reconstructions. Baseline anxiety was greater in women who chose bilateral compared to unilateral implant reconstructions (p=0.001). There was no difference in anxiety levels between groups postoperatively. Postoperatively, women who chose CPM with implant reconstructions were more satisfied with their breasts than women with unilateral reconstructions (p=0.034). CONCLUSIONS Though higher postoperative complications were observed following CPM and reconstruction, these procedures were associated with decreased anxiety levels and improved satisfaction with breasts for women who underwent implant reconstructions.

Current Trends in Postmastectomy Breast Reconstruction

“…The results revealed that patients choosing CPM with bilateral implant-based reconstruction experienced significantly improved satisfaction with breasts as measured by the BREAST-Q along with reductions in anxiety and worry about future cancer episodes on the GAD-7 and PROMIS-29 anxiety inventories. Not surprisingly, CPM was associated with greater rates of complications whether a patient received prosthetic or autologous reconstruction[26] [27]. In a separate study looking at the contribution of various factors, young age and availability of IBR, explained the greatest variation in receipt of CPM with the coefficient of determination being 32% and 29% respectively[8].…”

Postoperative complications in combined gynecologic, plastic, and breast surgery: An analysis from National Surgical Quality Improvement Program

“…Many patients undergo coordinated breast cancer surgery in association with an immediate reconstruction inclusive of contralateral prophylactic mastectomy (CPM). Previous studies have demonstrated increased postoperative complications in breast cancer patients who undergo bilateral mastectomy as compared with unilateral mastectomy . Patients who undergo contralateral prophylactic mastectomy have higher rates of overall complications and wound complications …”

Commentary on the Consensus Statement of the American Society of Breast Surgeons on Contralateral Prophylactic Mastectomy

“…2 Some studies found lower rates of regret, 2 and studies of more contemporary patients using the BREAST-Q PRO instrument 14 found that CPM with reconstruction was associated with equal or better breast satisfaction and psychosocial, physical, and sexual wellbeing. [10][11][12] …”

“…For example, it would be helpful to include information about absolute risk 9 for surgical complications and for contralateral breast cancer after CPM, as well as more recent data on quality of life after CPM. [10][11][12] In addition, women should be provided with information about breast reconstruction options 13 and should be encouraged to consult with a reconstructive surgeon 1 to ensure that they are better informed about the potential benefits and risks of reconstructive procedures before making a final decision. Recent studies that collected patient-reported outcomes (PROs) using a wellvalidated, breast surgery-specific instrument (BREAST-Q) 14 demonstrate that breast reconstruction can improve women's satisfaction as well as their psychosocial, physical, and sexual well-being after mastectomy.…”

“…For example, it would be helpful to include information about absolute risk 9 for surgical complications and for contralateral breast cancer after CPM, as well as more recent data on quality of life after CPM. [10][11][12] In addition, women should be provided with information about breast reconstruction options 13 and …”