Krebswissenschaft und -therapie

Decision Making Process for Risk Reducing Mastectomy in a Comprehensive Cancer Center

Abstract

Daniele La Forgiaa, Annarita Fanizzia, Sergio Diotaiutib, Rosanna Altierib, Margherita Patrunoc, Maria Digennaroc and Angelo Virgilio Paradisoc

Background: Risk Reducing Mastectomy (RRM) is a rising practice chosen by the woman to reduce an unacceptable high breast cancer risk. Current guidelines are considering such a practice in presence of suggestive family history and/ or BRCA 1/2 genetic pathogenic mutations. However, it has been reported that in clinical practice other factors (surgeon attitude, women psychological traits, cultural/geographical aspects) are playing a role in the decision process for RRM.

Method: We analyzed the characteristics of a consecutive series of women who received RRM in the Comprehensive Cancer Institute of Bari; in particular information on BRCA test, family history, diagnostic imaging, clinical pathological factors were collected.

Results: A consecutive series of 59 women receiving RRM was retrospectively selected. No Mammographic/NMR breast characteristics supporting the need for RRM were present. 8 (14% had a bilateral RRM while 51 (86%) a contralateral RRM (CRRM). The decision to receive a RRM was based on the presence of a BRCA alteration in 31/59 (53%) of cases, but, interestingly, 47% of women women decided for such a surgery even with a genetic test negative for BRCA mutations (17%) or with BRCA genetic test not performed (30%). Bilateral RRM was chosen only by women carrying a germline BRCA mutation. The decision for a CRRM was not based on specific primary tumor characteristics and performed in one time with respect to primary surgery in 26/51 cases while in the remaining subgroup of women in a delayed time. The multivariate analysis confirmed BRCA test stronger but not unique factor influencing the decision for RRM.

Conclusion: We confirm the prevalent role played by BRCA test in the decision of women to have a RRM but other factors seem to be able to suggest this practice also when no clear clinical benefit could be expected. In order to reduce the heterogeneity of approach to such practice, we suggest that: a) A multidisciplinary approach should be guaranteed; b) A clear intra-hospital clinical pathways should be adopted; c) Social education attenuating the perception of risk and expectations for such preventive practice should be activated.