Mastectomy For Treatment, For Prevention, For Prophylaxis Not as Simple as Following Data

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1 Mastectomy For Treatment, For Prevention, For Prophylaxis Not as Simple as Following Data Nathalie Johnson, MD FACS Medical Director, Legacy Cancer Institute and Breast Health Centers

2 Objectives Understand data on mastectomy versus breast conservation Knowledge on genetic mutations other than BRCA 1 and 2, panel testing for risk Broad understanding of indications for prophylactic mastectomy over and above genetics Learn to factor in patient goals Look at decision making tools for breast surgery

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4 Mastectomy in Evolution Radical Mastectomy Modified Radical Mastectomy Subcutaneous mastectomy Modified Simple mastectomy Skin Sparing Mastectomy Nipple Sparing Mastectomy

5 Mastectomy in Evolution

6 Before and After

7 Nipple Sparing Mastectomy

8 Decision Making Between Breast Conservation and Mastectomy Physician discussion Multidisciplinary approach Options for radiation Distance to radiation Radiation concerns Future risks Surveillance Access to care

9 Offer Oncoplastic Techniques in Breast Conservation

10 Disease Implications for Unilateral Multi centric disease Large area of DCIS Small breast Large Invasive cancer Downstage with neoadjuvant therapy Recurrence of disease after previous treatment with breast conservation Involvement of the nipple Consider mastectomy Mastectomy

11 Defining Risk for Patients Considering Bilateral Mastectomies Traditional No family history or minimal history Low risk of additional breast cancer ~ 0.5% per year Genetic testing BRCA 1 and 2 If negative then no increased risk over average Invasive Lobular Slightly higher risk for contralateral cancer Estrogen positive Risk diminished by use of endocrine therapy

12 How Good Is Genetic Risk Assessment Ask questions about testing performed BRCA 1/ 2 is most commonly performed Misses almost 50% of genetic mutations Panel testing is more accurate?

13 Benefit of Panel Testing

14 Other Considerations for Prophylactic Mastectomies Friend or acquaintance with recurrence after lumpectomy Real desire to avoid repeat chemotherapy MRI screening or false positives Ongoing screening Symmetry Concerns about drugs for chemoprevention Decision Making in the Surgical Treatment of Breast Cancer:Factor Influencing Womens Choices for mastectomy and breast conservation: Beliviance E, Kesmodel S; Frontiers in Oncology pub 29 March 2016, dui: /fonc

15 Chemoprevention for Breast Cancer Benefits Reduces risk of additional breast cancer by 50-60% Actual reduction is ~ half of a 15% risk or 7% realized Reduction endures about 3 years past cessation of therapy Drawbacks Side effects Tamoxifen hot flashes, clots, uterine cancer Reduction of fracture risk Aromatase Inhibitors Arthralgia Osteopenia Increased fracture risk 11% increase Possible bisphosphanate use to correct bone loss Osteonecrosis of the jaw,concern for dental work

16 Breast Cancer outcomes with Breast Conservation versus Mastectomy BCT may give improved outcomes over mastectomy Netherlands data suggested benefit in survival to BCT Wisconsin patients 67% BCT,33% mastectomy alone 5 year DFS 92 vs 89% 10 years 80 vs 67%? Radiation benefit Legacy Data patients Advantage to BCT in Triple negative Stage 2 Legacy Data eval: Kathy Panwala MD

17 Arm the Patient with the Facts Don t Rush to Surgery Genetic testing pre op when indicated Neoadjuvant therapy Endocrine or chemo Allows time to explore options Puts initial fear and emotion into perspective Genomic profiling of tumor May influence future decision

18 Shared Informed Decision Making Breast Conservation Bilateral mastectomies

19 Background: Rise of Contralateral Prophylactic Mastectomies NIH consensus 1991 BCT preferred for early stage Tuttle 2007 SEER cancer registry database 142,755 pts treated surgically for stages I-III CPM increase >150% from All stages, no plateau 10K pts with unilateral breast cancer get CPM per yr Younger, favorable prognostic factors, lobular, prior CA Rate of BCT also increased: 52% to 60%