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Promising reversal in early-stage breast cancer surgical choices

NEW YORK 10/06 - Recent efforts to educate women with early-stage breast cancer on surgical options appear to be paying off, with rates of breast conservation on the rise and rates of contralateral prophylactic mastectomy (CPM) on the decline, new U.S. data suggest.

"This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized," report Dr. Jonas Nelson and colleagues with Memorial Sloan Kettering Cancer Center in New York.

Using three large national databases, the study team evaluated trends from 2005 to 2017 in rates of lumpectomy versus mastectomy and unilateral mastectomy versus mastectomy with CPM in more than 3.4 million women.

They found that lumpectomy rates were at their lowest between 2010 and 2013, with a significant increase thereafter.

Overall mastectomy rates started to decline significantly beginning in 2013. Rates of CPM, which increased rapidly from 2005 to 2013, have since stabilized.

Taken together, the results show for the first time a significant trend toward de-escalation in surgical treatment of early-stage breast cancer in recent years, the investigators write in JAMA Surgery.

They say further research is needed to understand the precise factors driving these changes as well as their association with patient-reported outcomes.

Putting the findings into perspective, the authors of an invited commentary note that, "despite equivalent oncologic outcomes of breast conservation and mastectomy, over the last two decades, clinicians have witnessed a dramatic increase in rates of women electing for bilateral mastectomy in the setting of early unilateral breast cancer."

"We clinicians have struggled to understand and address the potential clinical factors contributing to this trend, and more recent efforts have focused on patient education and decision aids to guide shared decision-making," write Dr. Laura Dominici and Dr. Tari King with Brigham and Women's Hospital in Boston.

The current study provides "needed and much welcomed" data that suggest these efforts may be paying off as rates of breast conservation appear to be rising and patients requiring mastectomy are less likely to elect for bilateral procedures, they say.

Despite the "good news" on rates of CPM, Dr. Dominici and Dr. King note that rates of bilateral mastectomy are still "most striking" in the youngest women, with up to 40% opting for bilateral mastectomy, even though most are not at increased risk identified by genetic testing.

Their own study of patient-reported outcomes (PROs) in young women with breast cancer showed significantly lower quality of life for women having bilateral mastectomies versus lumpectomy, even in the setting of reconstruction.

"This important work by Nelson et al demonstrates there is opportunity to turn the tide away from more extensive surgery. Incorporating PROs into the surgical decision-making process will be a critical component of this effort," write Dr. Dominici and Dr. King.

At the moment, however, PROs are not routinely incorporated into clinical care. "This is a missed opportunity," they conclude.

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