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What About the Other Breast?

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By: Isabelle Bedrosian, M.D., F.A.C.S.

"What about the other breast?" This is a question newly-diagnosed breast cancer patients are asking with increasing frequency. However, providing them with an appropriate answer has never been easy.

We've known for some time that removal of the opposite healthy breast, a procedure called contralateral prophylactic mastectomy (CPM), reduces the likelihood of a second breast cancer event (a contralateral breast cancer) down the road. The question we haven't been able to answer for our patients is whether this actually makes a difference in their survival.

If CPM reduces the odds of a contralateral breast cancer, then why might it not have any impact on survival? Why would there be a disconnect between reducing the likelihood of a second breast cancer and survival?

There are a number of reasons for this:

• For some women, there's a greater risk of dying of the cancer they currently have than of developing a contralateral breast cancer.

• Even if a contralateral breast cancer develops, in many cases it's caught early and is highly curable, thereby having no effect on survival.

• As women get older, other medical conditions may predominate and become more life-threatening than breast cancer.

• With newer dugs, especially anti-estrogens that are administered to a majority of breast cancer patients, the risk of contralateral breast cancer is diminished.

To provide patients with breast cancer more information about potential survival benefit of CPM, we undertook a study specifically focusing on the question of survival. We were able to demonstrate that for a small group of women, those diagnosed before age 50 with stage I or stage II, estrogen receptor negative breast cancer, there was a small, but measurable improvement in five-year breast cancer specific survival associated with undergoing CPM. For the rest of the study population, no similar benefit was seen.

How should these results be interpreted?
I believe they should bring to bear greater certainty to the recommendations, both for and against the procedure. For women who fall into the group where we detected a survival benefit, physicians should initiate a discussion about CPM. For the remainder of the breast cancer population, physicians should be able to state with greater certainty that CPM is not necessary to improve odds of survival from breast cancer.

At the national level, current recommendations for CPM among women who aren't BRCA mutation carriers, are largely vague and broadly derived. At the personal level, the decision to proceed with CPM is highly subjective, and greatly influenced by personal biases and fears. With the objective findings of our study, we hope that national guidelines may be made more precise and that for individual patients, the decision to proceed with CPM can be made more objectively and less out of fear.

Although this new data can help tailor more precise recommendations for CPM, the results shouldn't be interpreted as a mandate either for or against CPM. CPM is an irreversible procedure, so for some women, a 5 percent survival benefit may not be worth the potential emotional, psychosocial and quality of life issues that occasionally arise following CPM.

Conversely, among women where we saw no survival benefit associated with CPM, individual factors in the personal history of such women may make CPM a reasonable option to consider.

Listen to Isabelle Bedrosian , M. D. Ande George Chang M.D. discuss research on CPM on Cancer Newsline


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