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A ElSherif, S Armanyous, SA Valente
Cleveland Clinic Foundation

Contralateral prophylactic mastectomy (CPM) rates have substantially increased over the last decade. The purpose of this study was to examine the trends of CPM at the time of ipsilateral breast tumor recurrence (IBTR) and determine if CPM is mainly patient-driven, surgeon-specific or whether tumor biology has a crucial role in the decision making process.

An institutional retrospective review of the patients who developed IBTR after BCS at our institution from 2013-2019. Patients and tumor characteristics at recurrence as well as genetic testing and reconstruction were collected and analyzed in relation to the trends of CPM observed. Trends in CPM performance over time were analyzed and compared in 3 time periods: (1) 2013-2015; (2) 2016-2017; (3) 2018-2019. CPM performance was also compared among 6 surgeons performing the procedure.

A total of 96 patients presented with a unilateral cancer recurrence after IBTR. In total, 30% (n=29) underwent CPM at the time of IBTR. Patients who underwent CPM were younger at age at IBTR (48 vs. 60 yrs., p= < 0.0001) and had less comorbidities (p=0.038). Genetic counseling was offered to all patients at the time of recurrence. Overall, 53 patients underwent genetic testing and of those 26.4% were positive (15% of entire cohort). The CPM group was more likely to carry a genetic mutation (p= 0.0028). In the genetic negative group, 25% underwent a CPM. Those who were genetically negative and had a CPM were younger (46 vs. 52, p=0.03) and had a shorter time to recurrence than those who underwent unilateral mastectomy (7 vs 12 years, p=0.018)
Tumor characteristics (TNM staging, histology and adjuvant therapy), time to recurrence and performing surgeon were not predictors for CPM performance. However, patients were more likely to undergo a CPM if they received immediate reconstruction (p=0.0059). Trends in CPM showed a relative increase over the study time period. (Figure 1)

CPM decision continues to be mainly patient-driven with increasing trends over recent years. Young age at IBTR, positive genetic testing and receiving immediate reconstruction play a crucial role in the decision making process.

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