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Mastectomy may not eliminate need for future imaging, biopsy
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Mastectomy did not eliminate the need for additional breast imaging or biopsy among women who underwent the procedure for breast cancer, according to study results.
“Autonomy and choice in treatment are encouraged, and can be empowering for patients, but decision-making can also result in anxiety, fear and distress,” Soojin Ahn, MD, surgical oncologist in the department of surgery at Icahn School of Medicine at Mount Sinai, said in a press release. “Some patients might choose more extensive surgery with the hope that this will eliminate the need for breast imaging and biopsy later when, in fact, this is not necessarily the medically beneficial course.”
Ahn and colleagues analyzed data from a cohort of women who underwent unilateral (n=185) or bilateral mastectomy (n=200) between 2009 and 2015. Investigators assessed postmastectomy imaging and biopsy rates during an average follow-up period of 30 months (range, 3-75).
Nineteen (10%) of women who underwent unilateral mastectomy underwent imaging with ultrasound after surgery due to concerning findings on physical examination. Eleven (6%) underwent biopsy, and two (1%) of those biopsies revealed malignant findings.
Thirty-one (15.5%) of women who underwent bilateral mastectomy required imaging. Twenty-nine underwent ultrasounds — three-quarters of which were performed on the same side as the prior cancer — and two underwent MRI.
Sixteen (8%) patients underwent biopsy. Three of the 11 patients whose biopsies were on the same side as the previous cancer demonstrated malignancy, where all five biopsies performed on the opposite side as the prior cancer were benign.
HemOnc Today spoke with Ahn about the increase in the percentage of women with breast cancer who are eligible for breast conservation therapy but choose to undergo mastectomy instead, the factors that contribute to this decision, and how physicians can counsel their patients to help them make informed choices about their treatment.
Question: W hy do patients with breast cancer who are eligible for breast conse rvation therapy instead choose to undergo mastectomy?
A nswer : Historically, there has always been discrepancy in the rates of mastectomy among different demographics. In the literature, we have seen higher rates of mastectomy in rural areas, where sometimes patients do not have access to facilities that can provide radiotherapy after lumpectomy. More recently, we are seeing an increase in mastectomy overall. This has to do, in part, to more patient autonomy in making decisions about surgery. There is not an authoritative approach to surgical decisions anymore. Also, plastic surgery techniques have improved and there are more options for reconstruction. These factors all can play a role in the choice for mastectomy. We also are conducting more genetic testing to look for mutations that are linked to high-risk breast cancers.
Q: Are there certain patients who can forgo future screening?
A: Routine screening mammogram is not necessary after mastectomy, and some patients may wish to forgo future screening. However, after unilateral mastectomy, the unaffected breast should continue to be screened yearly. This does not mean that diagnostic imaging studies — including mammogram, ultrasound and MRI — may not be needed to investigate palpable findings after mastectomy.
Q: Can you explain the rationale for your study?
A: We wanted to see if we could come up with data that could give us realistic expectations for certain patients, because some patients do not need routine screening mammogram or imaging after surgery. However, this does not mean that imaging studies are eliminated entirely. My colleagues and I wanted to see if there were data that could quantify how many patients were undergoing breast imaging or biopsy after mastectomy. So, we conducted this retrospective review that included 441 patients from our institution’s breast cancer database between 2009 and 2015.
Q: What are the clinical implications of the findings ?
A: We live in an age in which clinicians need to be practicing evidence-based medicine. We need to be more informed and have better expectations for what we tell our patients.
Q: Can you offer any insights to help physicians counsel their patients so they can make informed choice about their treatment?
A: The optimal treatment approach always comes down to what the standard of care is, and decisions should be made utilizing evidence-based medicine. The most important part of decision-making in breast cancer treatment includes disease-specific factors, such as tumor size and location, molecular subtype and clinical stage. However, patient preference also should be taken into consideration. When it comes to a patient who has different options for treatment, having an informed conversation prior to surgery and letting the patient know the risks and benefits of the different treatment options is very important. – by Jennifer Southall
Reference:
Ahn S, et al. Ann Surg Oncol. 2018;doi:10.1245/s10434-018-6735-8.
For more information:
Soojin Ahn , MD , can be reached at Icahn School of Medicine at Mount Sinai, 1090 Amsterdam Ave., Suite 10A, New York, NY 10025; email: soojin.ahn@mountsinai.org.
Disclosure : Ahn reports no relevant financial disclosures.