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Over the entire cohort, lumpectomy rates decreased from 67.7% in 2003 to 66.4% in 2010 in contrast to women 45 years old or less, in whom the lumpectomy rates went from 61.3% in 2003 to 49.4% in 2010. Unilateral mastectomy went from 28.2% to 23.9% and CPM from 4.1% to 9.7% compared with women 45 years old or less, in whom unilateral mastectomy rates went from 29.3% to 26.4% and CPM rates from 9.3% to 26.4%. Age was the most significant factor related to increasing CPM rates: 19.7% of women between 41 and 45 years old underwent CPM vs 5.1% of women between 66 and 70 years old. There was substantial regional variation in surgical procedures for young women: lumpectomy rates were lowest in the West and CPM rates were highest in the Midwest. Multivariate logistic regression showed that women 45 years old or younger compared with women more than 45 years who underwent CPM were more likely to be Caucasian, treated at an academic/research institution, have larger tumors, higher grade, higher stage, and lobular histology.

Rates of contralateral prophylactic mastectomy (CPM) in the United States have increased by approximately 150% since 1988. X 1 Arrington, A.K., Jarosek, S.L., Virnig, B.A. Patient and surgeon characteristics associated with increased use of contralateral prophylactic mastectomy in patients with breast cancer. Ann Surg Oncol.

2009; 16: 2697–2704 , x 2 Yao, K., Stewart, A.K., Winchester, D.J. Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007. Ann Surg Oncol. 2010; 17: 2554–2562 , x 3 Tuttle, T.M., Habermann, E.B., Grund, E.H. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007; 25: 5203–5209 , x 4 Tuttle, T.M., Jarosek, S., Habermann, E.B.

Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ. J Clin Oncol. 2009; 27: 1362–1367 Although prophylactic mastectomy is an established option for women with a genetic predisposition or otherwise significantly elevated breast cancer risk, the role of CPM in the management of the newly diagnosed patient with breast cancer remains controversial. X 5 King, T.A., Sakr, R., Patil, S. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol.

2011; 29: 2158–2164 Despite the lack of evidence for a survival benefit from CPM and the relatively low risk of contralateral breast cancer in women with unilateral early stage breast cancer, an increasing number of women continue to pursue this option. Increased CPM rates have been shown to be linked to young patient age, x 2 Yao, K., Stewart, A.K., Winchester, D.J. Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007. Ann Surg Oncol. 2010; 17: 2554–2562 , x 3 Tuttle, T.M., Habermann, E.B., Grund, E.H. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol.

2007; 25: 5203–5209 , x 4 Tuttle, T.M., Jarosek, S., Habermann, E.B. Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ. J Clin Oncol. 2009; 27: 1362–1367 , x 5 King, T.A., Sakr, R., Patil, S. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol. 2011; 29: 2158–2164 , x 6 Gao, X., Fisher, S.G., and Emami, B.

Risk of second primary cancer in the contralateral breast in women treated for early-stage breast cancer: a population-based study. Int J Radiat Oncol Biol Phys. 2003; 56: 1038–1045 , x 7 Jones, N.B., Wilson, J., Kotur, L. Contralateral prophylactic mastectomy for unilateral breast cancer: an increasing trend at a single institution. Ann Surg Oncol. 2009; 16: 2691–2696 and although CPM rates continue to increase in patients of all ages, the increase in CPM is most marked in young women. Few studies, however, have examined trends in unilateral mastectomy or lumpectomy over the past decade, particularly among younger women.

Tuttle and colleagues x 3 Tuttle, T.M., Habermann, E.B., Grund, E.H. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007; 25: 5203–5209 studied invasive breast cancers using Surveillance Epidemiology and End Results (SEER) and reported that 6.7% of all women less than 39 years old underwent a CPM compared with only 1.3% of women greater than 70 years old, but they did not report rates of CPM for other age groups. They reported that 56.1% of all patients underwent breast conservation in 1998; this increased to 59.7% in 2003, but these rates applied to patients of all ages in the cohort.

X 3 Tuttle, T.M., Habermann, E.B., Grund, E.H. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007; 25: 5203–5209 In our previous study of the National Cancer Data Base (NCDB) looking at rates of bilateral mastectomy among Commission on Cancer (CoC)-accredited cancer centers, we showed that 10.5% of women less than 40 years old underwent CPM, but we did not examine lumpectomy rates. X 2 Yao, K., Stewart, A.K., Winchester, D.J. Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007.

Ann Surg Oncol. 2010; 17: 2554–2562 In this study, we hypothesized that the greatest increase in CPM would be seen among young women and that overall lumpectomy rates have dropped, but especially among young women. We used the NCDB to contrast trends in surgical procedures between young and older women and to determine what patient, facility, and tumor factors correlated with these trends.

In addition, our study contains data through 2010 and will represent the most contemporary data on surgical trends in young women newly diagnosed with breast cancer. The NCDB, a joint project of the American Cancer Society and the CoC of the American College of Surgeons, is a nationwide, facility-based, oncology data set that currently captures approximately 70% of all newly diagnosed malignant cancers in the United States annually reported from approximately 1,450 hospitals with CoC-accredited cancer programs. Data reported from these hospital-based cancer registries include patient demographics, American Joint Committee on Cancer (AJCC) staging and tumor histopathology characteristics, and use of surgical and adjuvant treatments. Area-based indicators of socioeconomic status and facility level characteristics are also available through the NCDB. Data are coded and reported according to nationally established protocols coordinated under the auspices of the North American Association of Central Cancer Registries (NAACCR).

The NCDB currently contains information on approximately 26 million cancer cases diagnosed since 1985. Aspects of the NCDB data have been described elsewhere. X 8 Winchester, D.P., Stewart, A.K., Bura, C. The National Cancer Data Base: a clinical surveillance and quality improvement tool. J Surg Oncol. 2004; 85: 1–3 , x 9 Bilimoria, K.Y., Stewart, A.K., Winchester, D.P.

The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol. 2008; 15: 683–690 All data within the NCDB are compliant with the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA). Institutional review board approval was not required for this study because no patient, provider, or hospital identifiers were examined, no protected health information was reviewed, and the analysis is retrospective. Factors examined as potential predictors of surgery type were patient age, race, insurance status, comorbidity index, median household income, tumor histology, tumor grade, facility type, facility location, and population density. These can be roughly divided into patient, tumor, and hospital factors. Patient age was divided into comparison groups (45 years old vs 45 years old).

Race was classified into similar categories as census population data (non-Hispanic white, black, Hispanic or Puerto Rican, Asian/Pacific Islander, Native American, and other). Insurance status was stratified as follows: uninsured, private, Medicaid, and Medicare. For comorbid disease, Dayo's modification of Charlson's comorbidity index was used.

X 10 Dayo, R.A., Cherkin, D.C., Ciol, M.A. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992; 44: 613–619 Income was determined by area-based measures calculated from US Census data based on the patient's ZIP code at the time of diagnosis. Census Bureau USC.

Available at:. Accessed December 9, 2013. Tumor size (T) and regional lymph node involvement (N) were categorized according to the AJCC 7 th edition guidelines. X 12 Edge, S., Byrd, D.R., Compton, C.C. AJCC Cancer Staging Manual. Springer, New York; 2010 Tumor histology was defined according to the International Classification of Disease for Oncology (ICD-O) into the following categories: ductal, lobular, and mixed. X 13 Fritz, A., Jack, A., Parkin, D.M.

ICD-O: International classification of diseases for oncology. World Health Organization, Geneva; 2000 Tumor grade was classified as 1, 2, and 3. Hospital factors were facility type, facility location, and population density. For this study, 3 hospital types were considered: academic/research, comprehensive community, and community. These CoC designations are based on the range of services offered by the cancer program, number of new cases seen annually, and participation in clinical research and resident training.

Cancer program accreditation. Available at:. Accessed December 9, 2013. Briefly, an academic/research program participates in training residents and is actively involved in both basic and clinical research. A comprehensive community hospital sees 750 or more new cancer patients and conducts weekly cancer conferences. Community hospitals treat at least 300 cancer patients of all types per year and have a full range of services for cancer care, but patients may be referred for portions of their treatment.

Facility location was based on the reported state of residence at diagnosis and categorized as Northeast (CT, MA, ME, NH, RI, VT), Atlantic (NJ, NY, PA), Southeast (DC, DE, FL, GA, MD, NC, SC, VA, WV), Great Lakes (IL, IN, MI, OH, WI), South (AL, KY, MS, TN), Midwest (IA, KS, MN, MO, ND, SD, NE), West (AR, LA, OK, TX), Mountain (AZ, CO, ID, MT, NM, NV, UT, WY), and Pacific (AK, CA, HI, OR, WA), as classified in the United States Census Report. Census Bureau USC. Census regions and divisions of the United States.

Available at:. Accessed December 9, 2013.

Population density was described as a metropolitan, urban, or rural setting. Over the entire cohort, lumpectomy rates dropped from 67.7% in 2003 to 66.4% in 2010, unilateral mastectomy went from 28.2% to 23.9%, and CPM from 4.1% to 9.7% ( Fig. 1A). There were 13.3% of patients who were 45 years old or less.

In women 45 years old or younger, lumpectomy rates dropped from 61.3% in 2003 to 49.4% in 2010, unilateral mastectomy went from 29.3% to 26.4%, and CPM from 9.3% in 2003 increasing to 24.1% in 2010 ( Fig. 1B). The strongest independent predictor of CPM was age: in 2010, 19.7% of women between the ages of 41 and 45 years old underwent CPM in comparison to 5.1% of women between the ages of 66 and 70 years old ( Fig. 2A). In addition, 54.5% of women between the ages of 41 and 45 years old underwent lumpectomy in comparison to 73% of women between the ages of 66 and 70 years old ( Fig. 2B).

Of all patients who underwent CPM in 2010, 15% had stage 0 disease, 46% had stage I, and 39% had stage II disease. Table 1 lists patient, tumor, and facility factors for women 45 years or younger, stratified by surgical procedure for all years of the study. Several notable differences are worth mentioning. Nearly 19% of Caucasians underwent CPM over the study period compared with only 8.9% of blacks and 9.8% of Asian Pacific Islanders. The rate of CPM was 17% at both academic/research facilities and comprehensive community centers compared with 11% at community centers.

There was substantial regional variation in surgical procedures, but lumpectomy and CPM rates did not differ significantly by population density. In addition, the rate of CPM was greater in patients with lobular carcinomas compared with ductal or mixed histologies.

CPM, contralateral prophylactic mastectomy. When women 45 years old or less were examined only in 2009–2010, the rates of lumpectomy, unilateral mastectomy, and CPM become more varied, especially by facility factors. In the Midwest (IA, KS, MN, MO, ND, SD, NE), 32.4% of women underwent CPM compared with 14.6% of women in the Northeast ( Fig. 3A; CT, MA, ME, NH, RI, VT); the lowest lumpectomy rate was in the West (41.7%, AR, LA, OK, TX) compared with the Northeast (58.8%; CT, MA, ME, NH, RI, VT; Fig. 3B). In addition, community programs performed the highest percentage of lumpectomy (60.1%) compared with comprehensive community (50.2%) and academic/research institutions (47.7%); comprehensive community and academic institutions performed similarly higher percentages of CPM (24.6%, 23.5%, respectively) compared with community programs (16.1%).

Independent predictors of CPM among women aged 45 years or less were race, insurance status, facility type, facility location, tumor size, grade, stage, and histology. Multivariate logistic regression showed that women 45 years old or younger compared with women more than 45 years old who underwent CPM were more likely to be Caucasian, have managed care or private insurance, be treated at an academic/research institution, have larger tumors, higher grade tumors, higher stage, and lobular histology ( Table 2).

Facility factors were among the strongest factors associated with CPM in women 45 years or less. Facilities located in the South (AL, KY, MS, TN), Midwest (IA, KS, MN, MO, ND, SD, NE), West (AR, LA, OK, TX), and Mountain regions (AZ, CO, ID, MT, NM, NV, UT, WY) performed CPM more than 2 times more frequently than facilities located in the Northeast (CT, MA, ME, NH, RI, VT). Academic facilities performed CPM 1.8 times (odds ratio OR 1.8, 95% CI 1.7 to 2.0) more frequently than community centers. Table 2 Multivariate Logistic Regression for Contralateral Prophylactic Mastectomy, Patients Age 45 or Greater Compared with Patients Older than 45, 2003–2010 Characteristic n% Odds ratio (95% CI) p Value Race Caucasian 33,424 88.4 1 ref.

Our study showed that the rate of CPM has continued to increase among all age groups over the most recent years (5.6% increase from 2003 to 2010), but when we examined younger women as a separate cohort we saw a much larger (15.8%) increase. More importantly, lumpectomy rates did not differ from 2003 to 2010 among all age groups, but dropped 11.9% among women 45 years old or younger. In comparison with academic and comprehensive community programs, community programs perform the highest rates of lumpectomy and the lowest rates of CPM. As in other studies, our data showed that Caucasian women are more likely to undergo CPM, as well as those with managed care or private insurance and more aggressive tumors.

Interestingly, our study showed marked regional variation in CPM and lumpectomy rates. Rates of CPM were highest in the Midwest (IA, KS, MN, MO, ND, SD, NE) and double that of the Northeast (CT, MA, ME, NH, RI, VT); lumpectomy rates were highest in the Northeast (CT, MA, ME, NH, RI, VT) and lowest in the West (AR, LA, OK, TX) and South (AL, KY, MS, TN). This regional variation has been demonstrated previously in a study using the NCDB, which showed a significant relationship between geographic region and initial treatment of breast cancer. Similar to our study, the highest percentage of patients who received lumpectomy as initial treatment was seen in the Northeast; the lowest percentage was seen in the South. X 16 Sariego, J. Regional variation in breast cancer treatment throughout the United States. 2008; 196: 572–574 A multi-institutional study published in 2006 also showed higher lumpectomy rates in the Northeast and the lowest rates in the Southeast, x 17 Chagpa, A.B., Studts, J.L., Scoggins, C.R.

Factors associated with surgical options for breast carcinoma. 2006; 106: 1462–1466 and an older study using Medicare data showed that breast conservation rates were also highest in the Mid-Atlantic and New England regions of the country.

X 18 Nattinger, A.B., Gottlieb, M.S., Veum, J. Geographic variation in the use of breast-conserving treatment for breast cancer.

N Engl J Med. 1992; 326: 1102–1107 In the study by Tuttle and colleagues, x 3 Tuttle, T.M., Habermann, E.B., Grund, E.H. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol.

2007; 25: 5203–5209 there was variability in CPM rates among different registries without trends across the different regions of the country; however, lumpectomy rates were not examined closely. Such regional variability is likely due to a multitude of factors, including availability of and access to resources such as radiation therapy, which can be a significant challenge in areas of the United States with a larger rural component, such as in the West and South. X 16 Sariego, J. Regional variation in breast cancer treatment throughout the United States.

2008; 196: 572–574 , x 17 Chagpa, A.B., Studts, J.L., Scoggins, C.R. Factors associated with surgical options for breast carcinoma. 2006; 106: 1462–1466 Advances in breast reconstruction also may contribute to a desire for bilateral surgery to achieve symmetry, and improved access to plastic surgeons likely influences CPM rates. Another study from our group using the NCBD has documented the increased use of postmastectomy reconstruction over the last decade. X 19 Sisco, M., Du, H., Warner, J.P. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new milleninum?

Evidence from the National Cancer Data Base. J Am Coll Surg. 2012; 215: 658–666 Patient-related factors, such as socioeconomic status and education level, also likely play a role in breast cancer treatment selection. Future studies more closely examining this regional variation are needed. This is one of the first studies to show a drop in lumpectomy rates over approximately the past decade. This drop in lumpectomy rates is more offset by an increase in bilateral rather than unilateral mastectomy rates, suggesting that women who are initial breast conservation candidates are opting for bilateral mastectomy.

The last publication of the NCDB to look closely at general lumpectomy rates for early stage breast cancer was in 1998; it showed that 58% of patients with stage 0 to I cancers were undergoing breast conservation. X 20 Bland, K.I., Menck, H.R., Scott-Conner, C.E. The National Cancer Data Base 10-year survey of breast carcinoma treatment at hospitals in the United States. 1998; 83: 1262–1273 In 1990, the NIH published consensus guidelines that recommended breast conservation for patients with early stage breast cancer, and several publications have monitored the impact of these guidelines on clinical practice, showing an overall increase in breast conservation rates in the 1990s with some disparities reported. X 21 White, J., Morrow, M., Moughan, J.

American College of Surgeons Commission on Cancer; American College of Radiology Patterns of Care Study. Compliance with breast-conservation standards for patients with early-stage breast carcinoma. 2003; 97: 893–904 , x 22 Lazovich, D., Solomon, C.C., Thomas, D.B.

Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. 1999; 86: 628–637 According to a Surveillance, Epidemiology, and End Results (SEER) study, 60% of patients with stage I and 39% with stage II cancers underwent breast conservation in 1995, which was a dramatic increase from 35% and 19% of stage I and II cancers, respectively, in the late 1980s. X 22 Lazovich, D., Solomon, C.C., Thomas, D.B. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. 1999; 86: 628–637 Our study demonstrates that age has the strongest influence on surgical decision making and identifies a patient population that may benefit from interventions aimed at modifying the increasing CPM rate while increasing knowledge and perceptions about surgical procedures for breast cancer.

Why women, particularly younger women, choose CPM is often rooted in reasons that current studies do not support. In a study of more than 100 young women who had undergone CPM, the number 1 reason to undergo CPM was the “desire to lower the chance of getting cancer in the other breast.” x 23 Rosenberg, S.M., Tracy, M.S., Meyer, M.E. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey. Ann Intern Med. 2013; 159: 373–381 In another retrospective survey study of women who had undergone either unilateral mastectomy or CPM, the most common reason women underwent CPM was due to “worry about getting another breast cancer.” x 24 Han, E., Johnson, N., Glissmeyer, M. Increasing incidence of bilateral mastectomies: the patient perspective.

2011; 201: 615–618 The risk of contralateral breast cancer is actually much lower than most patients perceive. A SEER study that examined contralateral cancer rates from 1973 to 1996 reported that only 3% of patients had a contralateral cancer at 5 years and 6% at 10 years. X 6 Gao, X., Fisher, S.G., and Emami, B. Risk of second primary cancer in the contralateral breast in women treated for early-stage breast cancer: a population-based study.

Int J Radiat Oncol Biol Phys. 2003; 56: 1038–1045 Moreover, contralateral breast cancer rates have been decreasing over the years, in part due to better adjuvant treatments such as hormonal therapies. X 25 Nichols, H.B., Berrington de Gonzalez, A., Lacey, J.V. Declining incidence of contralateral breast cancer in the United States from 1975-2006. J Clin Oncol. 2011; 29: 1564–1569 Indeed, for most patients, the risk of developing a contralateral breast cancer remains substantially lower than the risk of recurrence from their index cancer.

X 5 King, T.A., Sakr, R., Patil, S. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol. 2011; 29: 2158–2164 Nevertheless, women often overestimate their risk. One study reported that young women quoted a 10% risk of contralateral cancer at 10 years, x 23 Rosenberg, S.M., Tracy, M.S., Meyer, M.E. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey.

Ann Intern Med. 2013; 159: 373–381 while in another study women stated the risk was 31%. X 26 Abbott, A., Rueth, N., Pappas-Varco, S.

Perceptions of contralateral breast cancer: an overestimation of risk. Ann Surg Oncol. 2011; 18: 3129–3136 Clearly, a gap exists between patient knowledge of contralateral breast cancer risk and what is reported in the literature. Other common reasons young women choose CPM are for “peace of mind” or to “improve their survival,” x 27 Fisher, C.S., Martin-Dunlap, T., and Ruppel, M.B. Fear of recurrence and perceived survival benefit are primary motivators for choosing mastectomy over breast-conservation therapy regardless of age. Ann Surg Oncol. 2012; 19: 3246–3250 and patient anxiety plays a large role in the decision to undergo CPM.

A study from Australia and New Zealand asked 81 breast surgeons about their CPM rates and reported that increased CPM rates were not related to sex or age of the surgeon, but stated that “fear and anxiety” among patients was the most common reason women requested a CPM. X 28 Musiello, T., Bornhammar, E., and Saunders, C.

Breast surgeon’s perceptions and attitudes towards contralateral prophylactic mastectomy. 2013; 83: 527–532 Ironically, studies that have examined quality of life measures and psychosocial wellbeing have not shown differences between CPM patients and non-CPM patients. X 29 Geiger, A.M., West, C.N., Nekhlyudov, L. Contentment with quality of life among breast cancer survivors with and without contralateral prophylactic mastectomy. J Clin Oncol.

2006; 24: 1350–1356 , x 30 Koslow, S., Pharmer, L.A., Scott, A.M. Long-term patient-reported satisfaction after contralateral prophylactic mastectomy and implant reconstruction.

Ann Surg Oncol. 2013; 20: 3422–3429 One study that examined body image measures demonstrated that approximately one-third of women rated their body appearance negatively after CPM, but this study examined women a decade after their procedure and often with delayed contralateral surgery. X 31 Frost, M.H., Slezak, J.M., Tran, N.V. Satisfaction after contralateral prophylactic mastectomy: the significance of mastectomy type, reconstructive complications, and body appearance. J Clin Oncol. 2005; 23: 7849–7856 Rosenberg and associates x 23 Rosenberg, S.M., Tracy, M.S., Meyer, M.E. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey.

Ann Intern Med. 2013; 159: 373–381 reported that 42% of patients felt their sense of sexuality was worse than expected after CPM, and one-third reported that “self-consciousness about appearance” was also worse than expected. X 23 Rosenberg, S.M., Tracy, M.S., Meyer, M.E. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey. Ann Intern Med. 2013; 159: 373–381 Nonetheless, most studies have shown that women are satisfied with their decision to undergo CPM and if asked, would undergo the procedure again. X 23 Rosenberg, S.M., Tracy, M.S., Meyer, M.E.

Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey. Ann Intern Med. 2013; 159: 373–381 , x 31 Frost, M.H., Slezak, J.M., Tran, N.V.

Satisfaction after contralateral prophylactic mastectomy: the significance of mastectomy type, reconstructive complications, and body appearance. J Clin Oncol. 2005; 23: 7849–7856 , x 32 Soran, A., Ibrahim, A., Kanbour, M. Decision making and factors influencing long-term satisfaction with prophylactic mastectomy in women with breast cancer. Am J Clin Oncol. 2013 May 2; ( Epub ahead of print) More research in this domain is needed, especially studies that compare contemporary CPM cohorts vs those that choose to not undergo CPM. Lastly, data to support a survival advantage of CPM are sparse.

A recent Cochrane review reported that there was inconclusive evidence to show that CPM conferred a survival benefit. X 33 Lostumbo, L., Carbine, N., Wallace, J.

Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Review. 2004; 18: CD002748 A large SEER study showed that women under 50 years old with estrogen receptor-negative early stage tumors derived a disease-free survival benefit from CPM, x 34 Bedrosian, I., Hu, C.Y., and Chang, G.J. Population-based study of contralateral prophylactic mastectomy and survival outcomes of breast cancer patients. J Natl Cancer Inst. 2010; 102: 401–409 but the study was criticized due to short follow-up, its retrospective design, and use of an observational dataset.

X 35 Tuttle, T.M., Habermann, E.B., and Virnig, B. Re: Population-based study of contralateral prophylactic mastectomy and survival outcomes of breast cancer patients. J Natl Cancer Inst. 2010; 102: 1371–1372 ( author reply 1372–1373) A recent analysis by our group that examined CPM's overall survival benefit using the NCDB also concluded that the survival benefit was “minimal at best” because confounding and selection bias would likely explain any survival benefit seen in a large observational database like the NCDB.

X 36 Yao, K., Winchester, D.J., Czechura, T. Contralateral prophylactic mastectomy and survival: report from the National Cancer Data Base, 1998-2002. Breast Cancer Res Treat. 2013; 142: 465–476 Other studies have shown survival benefits from CPM, x 37 Brewster, A., Bedrosian, I., Parker, P.A. Association between contralateral prophylactic mastectomy and breast cancer outcomes by hormone receptor status.

2012; 118: 5637–5643 , x 38 Peralta, E.A., Ellenhorn, J.D., Wagman, L.D. Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer. 2000; 180: 439–445 but these are all retrospective in design and fraught with the same issues as in the studies mentioned previously. Given that a randomized trial of CPM is not likely to occur, only inadequate retrospective datasets are available to examine the survival benefit of CPM.

It is important, however, that women understand the distant recurrence risk associated with their breast cancer and that this distant recurrence risk will determine their overall survival rather than their choice of operation. These knowledge gaps provide opportunities for surgeons to develop educational materials and decision tools that will more accurately inform patients of the contralateral breast cancer risk, the lack of a survival benefit of CPM, and the psychosocial ramifications of CPM especially in young women. There are several limitations to our study. Given the retrospective nature, we do not know the criteria used in the surgical decision making for or against each type of surgery. Another limitation in using the NCDB is that family history and BRCA status are not recorded, and these factors would definitely influence surgical decision making about CPM. During this study period, increased availability of genetic testing may account for a portion of the increased use of CPM. We have shown regional variation in surgical trends, but these regions are broad areas of the country, and we do not have more specific information on the state, county, or practice.

It would be interesting to have further data regarding regions of the country where single large institutions exist in more rural areas of the US and how this influences surgical trends. Similarly, information on facility type is restricted to broad criteria based on volume and tumor board information. In conclusion, the rate of CPM continues to increase, with a quarter of younger women undergoing CPM. These women are more likely to be Caucasian, treated at an academic/research institution, and have more aggressive tumors. The decision to pursue CPM is multifactorial, and in the context of young patients, patient education and decision making tools are crucial to aid patients in accurately estimating their risk and understanding the true risks and benefits of CPM. Likewise, how CPM affects survival in these young women is important and needs to be examined in future studies. References.

1 Arrington, A.K., Jarosek, S.L., Virnig, B.A. Patient and surgeon characteristics associated with increased use of contralateral prophylactic mastectomy in patients with breast cancer. Ann Surg Oncol.

2009; 16: 2697–2704. 2 Yao, K., Stewart, A.K., Winchester, D.J. Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007. Ann Surg Oncol. 2010; 17: 2554–2562. 3 Tuttle, T.M., Habermann, E.B., Grund, E.H. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment.

J Clin Oncol. 2007; 25: 5203–5209. 4 Tuttle, T.M., Jarosek, S., Habermann, E.B. Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ.

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J Clin Oncol. 2009; 27: 1362–1367. 5 King, T.A., Sakr, R., Patil, S. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy.

J Clin Oncol. 2011; 29: 2158–2164. 6 Gao, X., Fisher, S.G., and Emami, B. Risk of second primary cancer in the contralateral breast in women treated for early-stage breast cancer: a population-based study. Int J Radiat Oncol Biol Phys.

2003; 56: 1038–1045. 7 Jones, N.B., Wilson, J., Kotur, L. Contralateral prophylactic mastectomy for unilateral breast cancer: an increasing trend at a single institution. Ann Surg Oncol. 2009; 16: 2691–2696.

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