Contralateral Prophylactic Mastectomy with Immediate Reconstruction: Added Benefits, Added Risks

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1 Contralateral Prophylactic Mastectomy with Immediate Reconstruction: Added Benefits, Added Risks Grant W. Carlson Wadley R. Glenn Professor of Surgery Divisions of Plastic Surgery & Surgical Oncology Emory University School of Medicine

2 Disclosures: None

3 Outline Predictors of contralateral prophylactic mastectomy () Potential benefits of Oncological Reconstructive Patient satisfaction Morbidity

4 Analysis of Prophylactic Mastectomy Immediate Reconstruction Variable n=174 (%) No n=272 (%) p value Age <0.001 Body mass index White Race 151 (86.8) 200 (73.8) Family history 90 (52) 90 (33.3) <0.001 Personal history 18 (10.3) 37 (13.6) 0.31 Preoperative MRI 98 (56.3) 106 (39) <0.001 BCT attempted 12 (6.9) 43 (15.8) Pinell-White et al. Ann Plastic Surg 2014

5 Analysis of Prophylactic Mastectomy Variable n=174 (%) No n=272 (%) p value Histology DCIS 39 (22.4) 66 (24.3) Ductal 107 (61.5) 171 (62.9) Lobular 24 (13.8) 32 (11.8) Stage 0 36 (20.7) 64 (23.5) I 54 (31) 62 (22.8) III 30 (17.2) 56 (20.6) 0.382

6 Contralateral Prophylactic Mastectomy Variable Odds ratio Confidence Interval P value Age <0.001 Race White 1.00 Reference Black Other Pinell-White et al. Ann Plastic Surg 2014

7 Contralateral Prophylactic Mastectomy Variable Family history Odds ratio Confidence Interval P value First degree relative <0.001 Second degree relative Preoperative MRI BCT attempted Pinell-White et al. Ann Plastic Surg 2014

8 Contralateral Prophylactic Mastectomy Potential Oncological Benefits does not eliminate the risk of contralateral breast cancer and does not markedly improve survival rates In young women (less 49 years) with early stage ERtumors only a small survival benefit Fear of recurrence and avoidance of radiation are cited as major reasons choosing TM and May alleviate patient s anxiety and limit future diagnostic imaging / biopsies

9 Contralateral Prophylactic Mastectomy Pathological Findings Benign 82.2% Incidental contralateral breast cancer 7 (4%) DCIS 4 Invasive ductal cancer 3 High risk pathology 24 (13.9%) Lobular carcinoma in situ 4 Atypical ductal hyperplasia 11 Atypical lobular hyperplasia 9

10 Contralateral Prophylactic Mastectomy 70% 60% 50% 40% 30% 20% 10% 0% Pinell-White et al. Ann Plastic Surg 2014

11 Reconstructive Methods 80% 70% 60% 50% 40% 30% Expander/Implant Latissimus TRAM 20% 10% 0% Pinell-White et al. Ann Plastic Surg 2014

12 Reconstructive Methods 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7.5% 7.7% 15.5% 38.6% 60.9% * 17.3% 36.4% 16.1% No Latissimus dorsi TRAM Expander/Implant No reconstruction * p<0.001 Pinell-White et al. Ann Plastic Surg 2014

13 Aesthetic Satisfaction Impact of Time From Reconstruction Appearance Shape Softness Size Projection Breast Q Hu et al. Plast Reconstr Surg 124: 1, 2009

14 Impact of on Patient Satisfaction MSKCC study 294 patients undergoing immediate implant based reconstruction No Breast Q questionnaire administered mean of 52 months from surgery Koslow et al. Ann Surg Oncol 20: ,2013

15 Patient Reported Satisfaction and Implant Reconstruction Breast-Q Mean score P-value Satisfaction with Breasts < No 54.9 Satisfaction with Outcome No 67.7 Multivariate analysis: strongest predictor of Satisfaction with Breasts (p=0.005) Koslow et al. Ann Surg Oncol 2013; 20:

16 Distribution of Complications and Immediate Reconstruction TM 26% None 50% Both 8% 16% Pinell-White et al. Ann Plastic Surg 2014

17 Complications Unilateral vs Bilateral Reconstruction None Minor Major 20 * 0 UM/implant n=44 /implant n=106 UM/TRAM n=95 /TRAM n=26 *P=0.006 Pinell-White et al. Ann Plastic Surg 2014

18 Predictors of Complications Multivariate Analysis Factor Odds ratio Confidence Interval P value Breast reconstruction None 1.00 Referent Expander/implant <0.001 Latissimus flap <0.001 TRAM flap <0.001

19 Conclusions Women who choose are more often young, white, and have a family history of breast cancer Preoperative breast MRI and failed breast conservation are contributing factors The increase in is mirrored by an increase use of implant reconstruction significantly increases the complication rate of immediate breast reconstruction

20 Contralateral Prophylactic Mastectomy with Immediate Reconstruction: Added Benefits, Added Risks Grant W. Carlson Divisions of Plastic Surgery & Surgical Oncology Emory University School of Medicine

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