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Cyllene R. Morris, DVM, PhD California Cancer Registry

Increase in the Use of Double Mastectomies for the Treatment of Early-Stage Breast Cancer in California. Cyllene R. Morris, DVM, PhD California Cancer Registry. R isk of contralateral breast cancer (BC) Estimated risk: 0.5% - 1% per year risk in BRCA1-BRAC2 carriers, family history

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Cyllene R. Morris, DVM, PhD California Cancer Registry

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  1. Increase in the Use of Double Mastectomies for the Treatment of Early-Stage Breast Cancer in California Cyllene R. Morris, DVM, PhD California Cancer Registry

  2. Risk of contralateral breast cancer (BC) • Estimated risk: 0.5% - 1% per year • risk in BRCA1-BRAC2 carriers, family history • risk if lobular carcinoma in situ (LCIS) (risk for invasive lobular carcinomas?) • risk in HR negative than HR+ breast cancers

  3. Prophylactic Contralateral Mastectomy (PCM) • After BC, limited options available: Tamoxifen (ER+), screening, and PCM • Radical procedure: for most women, no effect on survival • Exception: small benefit in young women with ER (-), higher risk of second primary?1 1 Bedrosian I, Hu CY, Chang GJ. J Natl Cancer Inst 2010;102:401-9

  4. Recent Increase in PCM • PCM rates from 1.8% in 1998 to 4.5% in 2003 (SEER): young age, white race, lobular tumors associated with PCM 2 • PCM doubled in NY between 1995-2005, similar predictors 3 2 Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. J ClinOncol2007;25:5203-9 3 McLaughlin CC, Lillquist PP, Edge SB. Cancer 2009; 115:5404-12

  5. Recent increase in Use of MRI

  6. Objectives Use data in the California Cancer Registry (CCR) database to: • Describe trends in PCM in California • Evaluate predictors of PCM

  7. Study Population • BC diagnosed 2000-2009 • AJCC Stages 0-II • Surgically treated • Microscopically confirmed • Only tumor ever diagnosed 156,106 cases

  8. Data Analysis • Proportions and trends tested by Chi-Square • Logistic Regression: Odds of receiving PCM as opposed to mastectomy or breast-conserving surgery

  9. Study Population

  10. Multivariate Odds Ratios (OR) for PCM

  11. Multivariate Odds Ratios (OR) for PCM * PCM not covered by Medicare

  12. Multivariate Odds Ratios (OR) for PCM All models adjusted to year of diagnosis

  13. Conclusions • Use of PCM in California increased 2 – 4 fold in all groups (except 75 and older) • Women more likely to opt for PCM if: • Young (< 40) • White • Privately insured • Married • Diagnosed with stage II or in situ • Lobular carcinoma • High grade, ER negative

  14. Possible Reasons (1): • Increased use of MRI • Incidence of LCIS in California: stable since 2000 BUT • If enhancement foci found, women may elect PCM and forgo further tests!

  15. Incidence of Lobular Carcinoma In Situ: California, 1988-2007

  16. Possible Reasons (2): • High risk of second tumor? • Women at high risk: BRAC1/BRAC2 carriers, family history • Genetic testing becoming mainstream (but no information available in CCR)

  17. Possible Reasons (3): • Fear • Risk usually overestimated: lack of information? • However, because of scrutiny, second cancers more likely to be detected early

  18. Possible Reasons (4): • Peace of mind (avoid stress of repeated screenings) • Cosmetic symmetry, if mastectomy recommended (None better than only one – but loss of sensation across the chest…) • Plastic surgeon preference (easier reconstruction)

  19. Comments in a newspaper article NYT: After Cancer, Removing a Healthy Breast March 8, 2010 • Get done with it • Fear of losing insurance • Society too obsessed with breasts • Chemo and radiation side effects • Lack of trust in medical professionals (specially when felt mishandled)

  20. Another option: waiting • Study of 27 patients (UK)* requesting PCM, not recommended by surgeon: • After 12 months “cooling” period: • All patients less anxious about risk • 23 (85.2%) glad after waiting • 4 (14.8%) still requested PCM * Chaundhry & Sahu, European BC Conference, March 2010

  21. Conclusion • Use of PCM increasing dramatically in California • Are patients getting all the facts? • Waiting may benefit low/moderate risk patients • Patients have the final decision and choose what feels right to them

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