More extensive surgery does not improve survival over less aggressive surgery in younger women with breast cancer, according to data presented at the 2022 American Society of Breast Surgeons Annual Meeting.1 The results of a retrospective study of nearly 600 patients showed that treatment with mastectomy had no impact on survival among younger women with breast cancer compared with lumpectomy. Survival rates were also similar across hormone receptor and HER2 subtypes.
Within the hormone receptor–positive/HER2-negative group, however, failure to comply with hormonal therapy when prescribed was associated with increased mortality. Additionally, Black women with triple-negative breast cancer had a 5.7 times increased risk of death.
“These results are particularly significant because younger women are increasingly being diagnosed with breast cancer, despite low rates overall, and a growing number are undergoing mastectomy and even prophylactic bilateral mastectomy rather than breast-conserving surgery,” said lead study author Christine Pestana, MD, breast surgical oncology fellow at Atrium Health, Levine Cancer Institute, Winston-Salem, North Carolina. “Studies like this show that lumpectomy, a far less aggressive approach with fewer potential complications and morbidity, is equally as effective as removing an entire breast in appropriate cases.”
According to Dr. Pestana, breast cancer in young women is relatively uncommon, with 1 in 68 developing the disease by the age of 40. Compared with their older counterparts, however, young women with breast cancer present with more advanced disease and face poor outcomes, increased recurrence, and decreased survival.
“The growing number of young women with breast cancer has fueled interest in exploring the unique needs of this patient population,” said Dr. Pestana. She noted that a woman’s choice of surgical treatment “may affect her quality of life for many years.”
Although mastectomy entails removal of the entire breast, including the nipple and areola, and is frequently accompanied by breast reconstruction, breast conservation or lumpectomy refers to removal of the tumor with preservation of surrounding breast tissue and is often followed by radiation therapy. Additionally, some women with early-stage breast cancer choose to have their healthy breasts removed (contralateral prophylactic mastectomy). This decision may be due to multiple reasons including known genetic mutations, significant family history, or patient preference, said Dr. Pestana.
Mastectomy vs Lumpectomy
As Dr. Pestana reported, a large body of literature supports that breast conservation is equivalent to mastectomy with respect to survival outcomes. The American Society of Breast Surgeons consensus guidelines recommend breast conservation in appropriate candidates with early-stage breast cancer.
“Generally, the rate of complications has been higher with mastectomy than with breast conservation, and they include an increased risk of wound infection, bleeding, and chronic pain,” said Dr. Pestana. “Additionally, recent data of young breast cancer survivors demonstrated that patients who underwent breast conservation compared with mastectomy reported higher quality of life with respect to breast satisfaction in addition to psychosocial and sexual well-being.”
However, a national trend toward mastectomy in young women continues to persist. Because the consensus guidelines are derived through trials that historically excluded young women, explained Dr. Pestana, some providers may be hesitant to extrapolate these data for the management of younger patients. There are also patient-related factors that may contribute to this trend, including concerns about the cosmesis of lumpectomy, apprehensions about radiation therapy, and the peace of mind that comes with removal of all breast tissue due to fear of cancer recurrence.
According to Dr. Pestana, the rates of contralateral prophylactic mastectomy are increasing in a shift known as the “Angelina Jolie” effect, which was popularized after the actress publicly announced her decision to remove both breasts. “Many do not realize that Angelina Jolie was diagnosed with a genetic mutation predisposing her to a very high risk of developing breast cancer,” said Dr. Pestana. She noted that the current consensus regarding contralateral prophylactic mastectomy states that “removal of a healthy breast does not provide survival benefit in those at average risk for breast cancer.”
Importance of Patient Counseling
For this retrospective study of a prospective, age-selected database, Dr. Pestana and colleagues reviewed 591 women younger than age 40 who were diagnosed with nonmetastatic breast invasive cancer between 2010 and 2019 and received surgical intervention at Levine Cancer Institute. Patients who presented with stage IV disease, those with ductal carcinoma in situ, and men with breast cancer were excluded from the analysis. Researchers collected patient demographics, tumor characteristics, and treatment details and stratified patients based on molecular subtype. The time to follow-up was 67 months, and the median age for the cohort was 37.
“As expected, the results of the study showed that most of our patients (64%) underwent mastectomy, whereas just 35% underwent breast conservation,” said Dr. Pestana.
Although no association between surgical approach and survival was found in young women with breast cancer, compliance with hormonal therapy in the hormone receptor–positive group was associated with improved survival. Black race was also associated with an increased risk for death in triple-negative breast cancer. After the investigators accounted for all other risk factors, Black women with triple-negative disease were 5.7 times more likely to die than their White counterparts.
“These findings highlight the importance of counseling patients regarding outcomes to reduce unnecessary morbidity from more extensive surgical procedures,” said Dr. Pestana. “In addition, our results emphasize the need for future attention to racial outcome disparities in young women.” She concluded: “The final decision regarding surgical approach should be one of shared decision-making. Our job is to provide education and support our patients throughout their breast cancer journey, with a focus on oncologic safety and quality of life.”
Expert Point of View
Sarah Blair, MD, FACS
Sarah Blair, MD, FACS, Professor of Surgery at the University of California, San Diego, and Vice Chair of Academic Affairs in the Department of Surgery, said that both surgeons and patients have a bias that more aggressive treatment (ie, surgery) for younger patients will equal better survival.
“Young patients potentially will be alive for many years and are concerned about recurrence,” said Dr. Blair in an interview with The ASCO Post. “This study shows that the survival is similar with breast conservation, as long as patients continue to do surveillance and get treated for same-breast or new tumors in the opposite breast.”
“Mastectomy is still appropriate for patients with large areas of calcifications or multiple tumors and for certain hereditary cancers with very high rates of second tumors,” Dr. Blair continued. “Many young women will be candidates for breast conservation.”
DISCLOSURE: Dr. Pestana reported no conflicts of interest. Dr. Blair reported no conflicts of interest.