HOUSTON - A preventive procedure to remove the unaffected breast in breast
cancer patients with disease in one breast may only be necessary in patients who
have high-risk features as assessed by examining the patient's medical history
and pathology of the breast cancer, according to researchers at The University
of Texas M. D. Anderson Cancer Center.
Their findings, published in the March 1, 2009 issue of
Cancer, may
help physicians predict the likelihood of patients developing breast cancer in
the opposite breast (contralateral breast cancer), stratify risk and counsel
patients on their treatment options.
"Women often consider contralateral prophylactic mastectomy (CPM) not because
of medical recommendation, but because they fear having their breast cancer
return," said Kelly Hunt, M.D., professor in the Department of Surgical Oncology
at M. D. Anderson and lead author on the study. "Currently it is very difficult
to identify which patients are at enough risk to benefit from this aggressive
and irreversible procedure. Our goal was to determine what characteristics
defined these high-risk patients to better inform future decisions regarding
CPM."
According to the researchers, approximately 2.7 percent of women diagnosed
with breast cancer choose to have CPM. Recent statistics have shown that the
rate of CPM in women with stage I-III breast cancer increased by 150 percent
from 1998 to 2003 in the United States. Potential reasons breast cancer patients
choose to undergo CPM include risk reduction, difficult surveillance and
reconstructive issues such as symmetry and/or balance.
To begin to classify such risk factors, researchers reviewed the cases of 542
women with breast cancer only in one breast who received CPM to remove the
second breast at M. D. Anderson from January 2000 to April 2007. Out of this
group, 435 patients had no abnormal pathology identified in the opposite breast,
25 patients had contralateral breast cancer identified at surgery, and 82
patients had abnormal cells (atypical ductal hyperplasia, atypical lobular
hyperplasia and lobular carcinoma in situ) that indicate a moderate to high-risk
for breast cancer development in the contralateral breast found at the time of
surgery.
Further analysis of the patients with contralateral breast cancer revealed
that a five-year Gail risk of 1.67 percent or greater; an invasive lobular
histology; and multiple tumors in the original breast were all strong predictors
for contralateral breast cancer. Patient race, estrogen receptor status and
progesterone receptor status were not associated with increased risk.
"We went from having very little information on the benefit of this procedure
for individual patients to identifying three independent and significant risk
factors," Hunt said. "Each provides valuable insight into how likely a woman is
to develop the disease in her other breast and enables physicians to make an
educated recommendation if a patient will potentially benefit from CPM."
The Gail model, typically used for patients without breast cancer, evaluates
factors such age, age at menarche, number and findings of previous breast
biopsies, age at first live birth and number of first-degree relatives with
breast cancer, has been validated in several studies to calculate the risk of
developing an invasive breast cancer over the next five years. The five-year
risk of 1.67 percent is traditionally used as the cutoff point for the
definition of "high risk."
"We've always known contralateral breast cancer risk is not the same for all
women and it is unnecessary to perform preventive mastectomies routinely. As we
begin to clarify the specific risk factors, the number of women undergoing CPM
may decrease and those with a low to moderate-risk may be more open to less
extreme options for risk reduction, such as hormonal therapy and newer agents
for prevention of breast cancer."
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In addition to Hunt, other M. D. Anderson researchers contributing to this
study include Min Yi, M.D., Funda Meric-Bernstam, M.D., Isabelle Bedrosian,
M.D., Gildy V. Babiera, M.D., Rosa F. Hwang, M.D., Henry Kruerer, M.D., all in
the Department of Surgical Oncology; Lavinia P. Middleton, M.D., in the
Department of Pathology; Banu K. Arun, M.D., in the Department of Breast Medical
Oncology; and Wei Yang, M.D., in the Department of Diagnostic Imaging.
About M. D. Anderson
The University of Texas M. D. Anderson Cancer Center in Houston ranks as one
of the world's most respected centers focused on cancer patient care, research,
education and prevention. M. D. Anderson is one of only 41 Comprehensive Cancer
Centers designated by the National Cancer Institute. For four of the past six
years, M. D. Anderson has ranked No. 1 in cancer care in "America's Best
Hospitals," a survey published annually in U.S. News and World Report.
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