Increase in the Use of Double Mastectomies for the Treatment of Early-Stage Breast Cancer - PowerPoint Presentation

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Increase in the Use of Double Mastectomies for the Treatment of Early-Stage Breast Cancer in California

Cyllene R. Morris, DVM, PhDCalifornia Cancer Registry

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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

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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?

11

Bedrosian I, Hu CY, Chang GJ. J Natl Cancer Inst 2010;102:401-9

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Recent Increase in PCMPCM rates from 1.8% in 1998 to 4.5% in 2003 (SEER): young age, white race, lobular tumors associated with PCM

2PCM doubled in NY between 1995-2005, similar predictors

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2

Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig

BA. J Clin Oncol 2007;25:5203-9

3 McLaughlin CC, Lillquist PP, Edge SB. Cancer

2009; 115:5404-12

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Recent increase in Use of MRI

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Objectives

Use data in the California Cancer Registry (CCR) database to:

Describe trends in PCM in California

Evaluate predictors of PCM

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Study Population

BC diagnosed 2000-2009

AJCC Stages 0-IISurgically treated

Microscopically confirmed

Only tumor ever diagnosed

156,106 cases

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Data AnalysisProportions and trends tested by Chi-Square

Logistic Regression: Odds of receiving PCM as opposed to mastectomy or breast-conserving surgery

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Study Population

PCM

BCS/Mastectomy

N

%

N%Race/Ethnicity

NH White 5,6735.2

102,843

94.8

NH Black

230

2.6

8,662

97.4

Hispanic

792

3.3

23,544

96.7

Asian/ PI

538

2.9

18,02197.1Age at DX < 401,14911.48,97088.6 40-543,3826.548,26493.5 55-641,6854.139,02595.9 65-747402.330,98897.7 75+2771.125,85698.9Marital Status Married4,8815.190,16694.9 Not Married2,2793.760,09796.3 Unknown732.52,84097.5

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PCM

BCS/Mastectomy

N%

N

%AJCC Stage

In Situ1,7025.1

31,416

94.9

(LCIS)

191

5.4

3,225

94.6

I

2,603

3.7

67,610

96.3

II

2,928

5.1

54,077

94.9ER Positive/Unk5,9484.4129,17395.6 Negative/Bord1,2855.123,93094.9Grade Low (I/II) 3,8874.191,85995.9High (III/IV)3,3465.261,24494.8Histology Lobular15646.422,87993.6

Other

5,669

4.2

130,224

95.8

Insurance Private/Other

6,055

5.6

101,644

94.4

Medicare

707

2.2

31,486

97.8

Medicaid

338

2.3

14,333

97.7

Not/Unknown

135

2.3

5,648

97.7

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FACTOR

OR

95% CI

Histology

Ductal

/Other

1

-

Lobular

1.71

1.61 – 1.81

AJCC Stage

Stage I

1

-

In

Situ

1.28

1.21 – 1.36

Stage

II

1.21

1.14 – 1.30Tumor GradeLow (I/II)1High (III/IV)1.171.11 – 1.24

ER Status

Positive/

Unk

1

Negative

1.08

1.01 – 1.16

Multivariate Odds Ratios (OR) for PCM

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FACTOR

OR

95% CI

Insurance

No

/Unknown

1

-

Medicaid

1.00

0.82 – 1.23

Medicare*

1.65

1.36 – 2.00

Private/Other

2.13

1.79 – 2.53

Race/Ethnicity

White

1

-

Black

0.430.38 – 0.49Hispanic0.500.46 – 0.54

Asian/PI

0.42

0.39 – 0.46

Multivariate Odds Ratios (OR) for PCM

* PCM not covered by Medicare

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FACTOR

OR

95% CI

Age at DX

≥ 75

1

-

65

– 74

1.12

1.01 – 1.24

55 – 64

1.82

1.66 – 2.00

40

– 54

2.85

2.62 – 3.10

< 40

4.76

4.37 – 5.18

Marital Status

Not Married1-Married

1.17

1.11

– 1.23

Multivariate Odds Ratios (OR) for PCM

All models adjusted to year of diagnosis

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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

MarriedDiagnosed with stage II or

in situLobular carcinoma

High grade, ER negative

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Possible Reasons (1):

Increased use of MRIIncidence of LCIS in California: stable since 2000

BUT

If enhancement foci found, women may elect

PCM and forgo further tests!

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Incidence of Lobular Carcinoma In Situ:

California, 1988-2007

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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)

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Possible Reasons (3):Fear

Risk usually overestimated: lack of information?

However, because of scrutiny, second cancers more likely to be detected early

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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)

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Comments in a newspaper article NYT:

After Cancer, Removing a Healthy Breast March 8, 2010Get done with it

Fear of losing insuranceSociety too obsessed with breasts

Chemo and radiation side effects

Lack of trust in medical professionals (specially when felt mishandled)

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Another option: waiting

Study of 27 patients (UK)* requesting PCM, not recommended by surgeon:After 12 months “cooling” period:

All patients less anxious about risk23 (85.2%) glad after waiting

4 (14.8%) still requested PCM

* Chaundhry & Sahu, European BC Conference, March 2010

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Conclusion

Use of PCM increasing dramatically in CaliforniaAre patients getting all the facts?

Waiting may benefit low/moderate risk patients

Patients have the final decision and choose what feels right to them