The growth of prophylactic mastectomy

In addition, the panel states that contralateral mastectomy in a woman already diagnosed with unilateral bad cancer and treated by mastectomy is "discouraged," while the operation in a woman treated with lumpectomy is "strongly discouraged" ".

Breast surgeons go further, ^[2] saying that "with the possible exception of BRCA carriers ," contralateral prophylactic putty "ctomy" does not appear to be badociated with a survival benefit. "They say that the procedure should be reserved for women with the highest risk of contralateral bad cancer, namely those with mutations BRCA1 / 2 and those with a risk of bad cancer. bad cancer greater than 25%, and on the other hand, "medium-risk" women at risk of bad cancer in the bad is 0.1% to 0.6% per year should be "discouraged Having a contralateral prophylactic mastectomy because they "do not derive any oncological benefit." They point out not only that the operation doubles the risk of surgical complications as compared to bad cancer treatment alone, but also that 39, she can "affect Negative oncology results "by delaying adjuvant therapy or discouraging women from undergoing radiotherapy. The Working Group on Breast Diseases in Oncology agrees, pointing out that there is a lack of reliable evidence to support contralateral prophylactic mastectomy. ^[3] Women at high risk should therefore be counseled on alternative management strategies, including chemoprevention and surveillance imaging. . Nevertheless, the group recognizes that the decision "must be individualized" because "there is no formula for predicting whether the patient will achieve peace of mind."

The evidence supports the guidelines

not just based on expert opinions or consensus discussions, but on large datasets from dozens of studies. For example, prophylactic mastectomy in women with BRCA1 / 2 mutation or in women with a family history of bad cancer is confirmed by numerous studies showing that the risk of developing bad cancer is reduced. by at least 90% ^[4,5,6,7]

By cons, a large recent study on the registry has demonstrated that, in women who have previously been diagnosed with bad cancer, there is no Improvement of survival by the removal of both bads

. Nearly 19,000 Californian women diagnosed with stage 0-III unilateral bad cancer showed that bilateral mastectomy was not badociated with a difference in mortality from bad-conserving surgery and radiation

. 19659023] indicated that there was "insufficient evidence" to suggest that contralateral prophylactic maitectomy improved survival, and concluded that doctors are in agreement

Due to this mbadive consensus, the clinicians speak with one voice

Lisa A. Newman, MD, director of the Henry Ford Health System's bad oncology program in Detroit, Michigan, told Medscape that for women with BRCA mutation Bilateral prophylactic mastectomy may be a "valid" option because it can reduce bad cancer from 40% to 85% to less than 10%.

Steven A. Narod, MD, of the Women & # 39; s College Research Institute of Women & # 39; s College Hospital in Toronto, Ontario, Canada, pointed out that the procedure must still be performed early, usually between 25 and 30 years. "Once you have reached 30 [years of age] with a BRCA mutation your risk begins to become, on an annual basis, quite significant, so if you are going to do it, there is no scientific reason to expect "For women already diagnosed with bad cancer, Newman said that contralateral mastectomy can be" very effective as the most aggressive strategy to prevent bad cancer "in the other bad, reducing the risk up to 95% She pointed out that this "does not constitute a guarantee against future bad cancer" because women can have microscopic bad tissue in the surrounding areas of the body, such as the wall thoracic or armpit area.

The overall risk of developing bad cancer in a "medium risk" woman is 12%. Prophylactic mastectomy reduces this to 2%, which, according to Newman, does not outweigh the risks and the psychosocial impact of the procedure.

She also pointed out that the early and conservative treatment of bad cancer is successful in the majority of cases. In other words, as Ashu Gandhi, MD, PhD, an executive member of the UK Breast Surgery Association, summed up, "In the History of the Family / BRCA there is a justified reason to remove healthy bads, but in the group [lower-risk] – the group "woman next door" – there is no clinically justifiable reason for Remove both bads

Despite all the recommendations and data from large-scale studies, there is "no question" that there has been a "trend" Increasingly at a Larger Surgery "over the past 15 years, said Nora Jaskowiak, MD, an badociation.The Surgical Professor and Surgical Director of the Breast Center at the University of Chicago Medicine, Chicago, Ill. [19659018] "Usually, this most important surgery is a bilateral mastectomy," she told Medscape, "Every week, patients Do not save their bad, get irradiated, and do very, very well choose to have a bilateral mastectomy. "

This impression is confirmed by a recent badysis of data on over 230,000 American women, which shows that younger women likely to choose a bilateral mastectomy plus immediate bad reconstruction rather than a conservative bad surgery, regardless of their response to neoadjuvant chemotherapy

According to Medscape, bilateral mastectomy rates with immediate reconstruction increased significantly between 2010 and 2014, from 8.0% to 13.2%, even though full response rates pathological to neoadjuvant chemotherapy went from 33.3% to 46.3% during the same period

.An earlier, 19,000 women with early-stage bad cancer emphasized this trend , the proportion of women undergoing bilateral mastectomy increased from 2.0% in 1998 to 12.3% in 2011, an annual increase of 14.3%

. have increased fastest among women under 40 years of age. All this despite studies showing that having a bilateral mastectomy can have serious consequences for women.

A study in more than 18,000 women reported by Medscape showed that compared to a unilateral or single mastectomy, contralateral prophylactic mastectomy is badociated with a significant increase. Another badysis of nearly 600 women followed at about 2 years of age showed that contralateral mastectomy was also badociated with an increased risk of superficial necrosis of the bad, scarring of the scar, and rupture of the prosthesis. and infections requiring oral antibiotics, as well as an increased risk of exposure to implants. ^[9]

Although women undergoing a contralateral prophylactic mastectomy may have increased bad satisfaction by having both reconstructed at the same time, a systematic review of 22 studies suggested that the procedure may affect badual well-being and somatosensory function ^[10] . colleagues ^[11] found in a survey of over 480 women that contralateral prophylactic mastectomy may have adverse effects on body appearance, femininity, and badual relations, affecting between one-quarter and one-fifth of women [19659018] cancer that under bilateral prophylactic mastectomy may experience psychological problems, with one study suggesting that nearly half feel embarrbaded, less badually attractive, and dissatisfied with scars. ^[12]

Why Do Women Choose Bilateral Mastectomy?

So why do women opt for invasive surgery, such as contralateral prophylactic mastectomy, putting themselves at risk for adverse effects and more serious psychological disorders while overall benefit could be as important, if not more, with less invasive treatments? "People have been watching this a lot for the last 10 years," said Jaskowiak, "and I think there are a lot of different factors."

A study of nearly 3,000 women suggests that independent predictors of undergoing contralateral prophylaxis mastectomy includes the Caucasian race, the age of less than 50 years, MRI at the time of diagnosis, the possibility immediate bad reconstruction and unsuccessful attempt at bad conservation. ^[13]

Another study, including more than 3,600 women, suggested that contralateral prophylactic mastectomy was related to a higher level of education, a family history of bad cancer, and a history of bad cancer. the availability of private medical insurance alongside young people and whites. ] [14]

In their study of nearly 1500 women, Hawley and colleagues ^[15] added genetic testing, regardless of whether the result was positive or negative, to factors badociated with mastectomy. contralateral prophylaxis, with a greater concern for recurrence. This finding was supported by a group study of women with stage 0-III bad cancer who were younger than 40 years of age, revealing that women who opted for contralateral prophylactic mastectomy were often concerned about by a future bad cancer. ^[16]

Narod tells Medscape that although genetic testing and the increasing acceptance of bilateral mastectomy as a procedure have fueled its growth, the reason that has been "l & # 39; The deepest impact is that we scared women so much. "

"There is a high level of basic anxiety – they are so concerned about everyday life under the stress of anxiety that mastectomy is the best way to relieve it," he said. -he says. "In other words, there are a lot of women – and I've seen a lot of them in my clinic – who are told that they have a high risk of cancer, whether because of from a mutation BRCA1 that it is single-nucleotide polymorphisms, mammographic density or the absence of children. "

They estimate therefore that "it's a matter of time, that translates into that free anxiety that results in insomnia." and some depression, and … other than psychotherapy or drugs, the better remedy is the bilateral mastectomy, "adds Narod.

Jaskowiak agrees:" Some women are so afraid of bad cancer that even if you tell them that will change their survival, they never want to suffer this again that they come across … an abnormal mammogram, additional tests and biopsies, and all that, they want to do everything that's they can to avoid having to go through all that. "

" I think it's not there, "she said, pointing out that even if the results came back negative, examining the other bad and the suffering of the procedure is disgusting for women

.
Everyone in the chat room says that I should have a bilateral mastectomy.

Jaskowiak believes that social media also played a role in women choosing contralateral mastectomy. "A lot of people tell me," Well, I went to a bad cancer chat room, and everyone in the chat room said that I should have a bilateral mastectomy.

"I do not know how many times Angelina Jolie has talked to me about women, and I have to remind them that they are not Angelina Jolie, that they have not of mutation and that she has never had cancer in the first place, "she added. However, should anxiety reduction be considered as an indication of contralateral prophylactic mastectomy?

Speaking to Medscape, Gandhi said that "the woman might say," Well, that does not bother you, but for me "However, the question of performing mastectomy as a form of reduction of "Anxiety" then becomes unscientific but philosophical, "he says.

"If we reduce anxiety, then is not it good? On our side, we falsely reduce anxiety because it has no effect on their prognosis, so it is bad. "

No matter, Gandhi said," Science is pretty safe, but it's very difficult to convince people of that, or it can be, depending on the patient you're dealing with. "

Can we

For Gandhi, it is clear that the drift towards ever more contralateral mastectomies is something that the medical profession "should certainly" try to counter.

The medical profession should try to which is scientifically true

He said that "scientifically, it's the right thing and the medical profession, at least, should try to do what is scientifically true."

However, how that should be done is another question.

Jaskowiak that "this is a problem that all bad surgeons are struggling with," adding that it will take "a lot of time and a lot of education," involving not only surgeons but also nurses and other members of the surgical team.

cited the example of Katharine Yao of NorthShore University HealthSystem in Evanston, Illinois, who developed a visual decision-making tool to explain the risk. "You can tell people that they have a 2.5% chance of getting bad cancer in their opposite bad in the next 10 years," Jaskowiak said, "but if they see these hundred people and only two of them are on, that sometimes ends up helping people. "

Gandhi agreed that education is the key, saying that more and more people should be informed that this does not happen makes no difference. However, he believes that "the doctor who tells them at the time of diagnosis is probably the least desirable point."

"If they hear about it before being diagnosed with bad cancer, it would be much better

One strategy that Jaskowiak believes can help reduce the number of bilateral mastectomies is to be more selective about patients who undergo MRI, and another would be if insurance companies reduce payment for they. "But it does not seem very patient-centered for this to be understood by the insurance companies," she said. "It seems that physicians should be able to talk to people and educate them."

In the UK, for example, the rate of contralateral mastectomy increases has been consistently lower than that in the United States .

Priestley, Clinical Nurse Specialist at the Charity Breast Cancer Care in London, UK, said that "it has something to do with our health care system and the fact that the National Health Service does not Not have the necessary financial resources.

"In reality, decisions are not dictated by finance, they are motivated by risk and benefits for someone as an individual," she said.

"We do a lot of things. the effort in the UK to deter the woman, and one of the reasons is, to put it very bluntly, we are not paid per case, "said Gandhi." In a care environment where you are paid per case, although you are ethical, you should give the correct medical information, there is a part of you that does not. "

But when it comes to the individual decision Patient, Newman pointed out that "[i] is important in meeting the emotional needs of every bad cancer patient and, as physicians, we should respect the woman's choice for a contralateral prophylactic mastectomy." [19659018] the patient is physically fit for the procedure, includes complications, if it is clear on the fact that its cancer survival / treatment needs is driven by the known cancer, and as long as it goes that she will always have days need surveillance to develop new bad cancer or recurrence of cancer, despite more extensive surgery. "

Clinicians who spoke to Medscape for this article did not reveal any relevant financial relationship.