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OfficialreprintfromUpToDate
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Contralateralprophylacticmastectomy
Author
SectionEditor
AneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)
RussellSBerman,MD

DeputyEditor
DonSDizon,MD,FACP

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Apr2015.|Thistopiclastupdated:Dec03,2014.
INTRODUCTIONAcontralateralprophylacticmastectomy(CPM)isariskreducingmastectomyperformedin
theclinicalsettingforthepatientdiagnosedwithaninvasiveoranoninvasivebreastcancer.Whilethereisno
clearsurvivalbenefitformostbreastcancerpatientswhodonotcarryadeleteriousBRCA1orBRCA2mutation
[13],theratesofperformingaCPMhaveincreasedoverthelastseveralyears[4,5].
Theriskofacontralateralbreastcancer,thedecisionmakingprocesstoundergoaCPM,andoutcomeswillbe
reviewedinthistopic.Managementofpatientswithinvasiveandnoninvasivebreastcancer,withandwithoutan
inheritedgeneticmutation,isreviewedseparatelyandincludes:
(See"Overviewofthetreatmentofnewlydiagnosed,nonmetastaticbreastcancer".)
(See"Ductalcarcinomainsitu:Treatmentandprognosis".)
(See"Treatmentprotocolsforbreastcancer".)
(See"BRCA1andBRCA2:Prevalenceandrisksforbreastandovariancancer".)
(See"ManagementofhereditarybreastandovariancancersyndromepatientswithBRCAmutations".)
RISKOFCONTRALATERALBREASTCANCERPatientswithaunilateralsporadicbreastcancerareata
modestriskofdevelopingacontralateralbreastcancer(CBC),andmostwomenneverwilldevelopacontralateral
secondprimarybreastcancer[6,7].Forpatientswhopresentwithunilateralbreastcancer,theriskofdevelopinga
contralateralbreastcancerisestimatedtobe0.5to1.0percent/yearcumulativeovertheirlifetime[8,9].However,
areviewof162patientswithsporadicbreastcancerfoundthatthe10yearcumulativeincidenceofcontralateral
breastwas1percent[10].(See"Patternsofrelapseandlongtermcomplicationsoftherapyinbreastcancer
survivors".)
ForpatientswhocarryadeleteriousBRCA1orBRCA2mutation,theriskofacontralateralbreastcanceris
approximately10to25percent[10,11].However,somestudieshaveestimatedtherisktobeashighas65
percentforBRCA1carriersand50percentforBRCA2carriers[12].(See"Managementofhereditarybreastand
ovariancancersyndromepatientswithBRCAmutations",sectionon'Treatmentandprognosisofwomenwho
developbreastcancer'.)
CONTRALATERALPROPHYLACTICMASTECTOMYRISKREDUCTIONBaseduponaprospectivestudy
of745womenwithbreastcancerandafamilyhistoryofbreastand/orovariancancerundergoingaCPM,therisk
reductionofacontralateralbreastcancer(CBC)wasapproximately96percent[6].Inthiscohort,therisk
reductionfollowingaCPMforwomenlessthanage50years(n=388)was94.4percentand96.0percentfor
women50yearsofageandolder.
DECISIONMAKINGPROCESSThedecisiontoundergoacontralateralprophylacticmastectomy(CPM)is
frequentlyanindividualchoiceandgenerallybaseduponpersonalpreferenceandmanagement(eg,mastectomy)
ofthepresentingbreastcancer.Inaddition,manywomenoverestimatetheiractualriskforcancerinthe
unaffectedbreast.Otherinfluences,includingthesurgeon,primarycarephysician,friends,and/orfamilymembers
areoftencitedassuggestingaCPM.Hence,thepatientandhersurgeonshouldfullydiscusstheactualrisksofa
contralateralbreastcancerintermsofthepatientsownpersonalandfamilyhistoryandhergoalsfortreatment.
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Anumberofsociodemographicandtumorcharacteristicshavebeenassociatedwithahigherlikelihoodof
pursuingcontralateralprophylacticmastectomy,including:
Youngerage[4,6,1316]
Caucasianrace[4,14,15]
Privatehealthinsurance[14]
Familyhistoryofbreastcancer[4,13,1517]
Noninvasivehistology[4]
Lobulartumorhistology[15,16,18]
Otherfactors,suchaspreoperativeevaluationwithabilateralbreastmagneticresonanceimaging(MRI)
[4,17],failedattemptatbreastconservationmanagement[4],andtheoptionofimmediatereconstruction
[4,15,17],areindependentlyassociatedwiththedecisiontopursuecontralateralprophylacticmastectomy.
Baseduponasurveyof123womenwithunilateralbreastcancer,mostwomenwhoundergoaCPMdoso
withadesiretoreducetheriskofacontralateralbreastcancer(98percent)andimprovesurvival(94percent)
[19].Only18percentbelievedthataCPMprolongedsurvival.
BRCA1orBRCA2mutationcarriersmoreaccuratelyperceivedtheirriskforcontralateralbreastcancer,
whereaswomenwithoutaknownmutationsubstantiallyoverestimatedthisrisk.DespiteknowingthatCPM
doesnotclearlyimprovesurvival,womenwhohavetheproceduredoso,inpart,toextendtheirlives.
Interventionsaimedatimprovingriskcommunicationinanefforttopromoteevidencebaseddecisionmaking
arewarranted[19].
OtherreasonsforundergoingaCPMincluderelativeeaseoffollowupwithoutamammogramorMRI,
reductionofanxietyforoccurrenceofasecondbreastcancer,anddesireforsymmetrythatcanbeachieved
withbilateralmastectomiesandreconstruction.
PatientsmustbemadeawareoftherisksandcomplicationsofundergoingaCPM,asthisinvolvesamore
extensiveoperation(bilateralmastectomieswithorwithoutbilateralreconstruction),andthatwhileriskof
contralateralbreastcancerisreduced[2,20],thedataregardingsurvivalbenefitsaremixed.(See'Outcomes'
below.)
POSTOPERATIVEMORTALITYANDMORBIDITYMortalityratesareuniformlylow(<1percent)inpatients
undergoinganelectivemastectomy[21,22].
Thecomplicationsofamastectomyincludeaseroma,surgicalsiteinfection(SSI),skinflapnecrosis,nipple
necrosis,postoperativepain,postmastectomypainsyndrome,phantombreastsyndrome,armmobilitylimitations,
pneumothorax,brachialplexopathy,andtherisksofananestheticandreconstruction,ifperformed.The
complicationsarediscussedseparately,including:
(See"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement",sectionon
'Complications'.)
(See"Clinicalmanifestationsanddiagnosisofpostmastectomypainsyndrome".)
(See"Postmastectomypainsyndrome:Riskreductionandmanagement".)
(See"Overviewofcomplicationsoccurringinthepostanesthesiacareunit".)
(See"Breastreconstruction:Preoperativeassessment".)
Thefrequencyofcomplicationsfollowingabilateralmastectomyisgreaterthanaunilateralmastectomy.
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Inaretrospectivereviewof600patientsundergoingamastectomy,patientsundergoingbilateral
mastectomies(n=209)hadsignificantlymoreoverallcomplicationscomparedwithpatientsundergoinga
unilateralmastectomy(41.6versus28.6percent)[23].Majorcomplications(eg,requiredreoperationfor
hematoma,rehospitalizationforSSI,flapornipplenecrosis)werealsosignificantlymorecommonfor
patientsundergoingbilateralmastectomies(13.9versus4.1percent).Whenadjustingforpotential
confounders,includingbodymassindex,age,stage,previousradiationtherapy,adjuvanttherapy,smoking,
anddiabetes,patientsundergoingaCPMwere1.5timesmorelikelytohaveanycomplication(oddsratio
[OR]1.53,95%CI1.042.25)and2.7timesmorelikelytohaveamajorcomplication(OR2.66,95%CI1.37
5.19).
AretrospectivereviewoftheAmericanCollegeofSurgeonsNationalSurgeryQualityImprovementProgram
(ACSNSQIP)databaseof4219breastcancerpatientsbetween2007and2010foundahigherSSIin
patientsundergoingaCPMcomparedwithaunilateralmastectomy(5.8versus2.9percent)[24].The30day
complicationratefollowingaCPMwassignificantlyhigher(7.6versus4.2percent),andadjustedforbody
massindexandsmokinghistory(OR1.9,95%CI1.32.8).
OUTCOMES
OverallsurvivalThereisnoclearoverallsurvivalbenefitformostbreastcancerpatientswhoundergoa
contralateralprophylacticmastectomy(CPM),andnorandomizedtrialshaveyetbeenperformed.However,for
patientswithadeleteriousBRCA1orBRCA2mutation,andinsomestudies,womendiagnosedatayoungage
(<50years),asurvivalbenefithasbeenattributedtoaCPM[1,2,5,20,25].
Thefollowingretrospectivestudiesandreviewillustratethecontemporaryfindings:
AriskstratifiedanalysisusingtheSurveillance,Epidemiology,andEndResultsdatabasefoundthatwomen
betweenages18to49years(n=3731)undergoingaCPMhadasmallimprovementinfiveyearadjusted
breastcancersurvivalcomparedwithwomenage50yearsandolder(n=5171,88.5versus83.7percent)
[1].
Ametaanalysisof39observationalstudiesandretrospectivereviewsthatincludedwomenundergoing
bilateralprophylacticmastectomiesaswellasCPMfoundthatthereislimitedevidencetosupportimproved
survivalwithaCPM[2].
Aretrospectivereviewof42breastcancerpatientsundergoingaCPMfoundnodifferenceinfiveyear
survivalcomparedwith195breastcancerpatientswithoutaCPMhowever,the10yearsurvivalfavoredthe
patientswhohadundergoneaCPM(81.3versus73.3percent)[5].ThesurvivalbenefitofaCPMpersisted
aftercontrollingforgeneticsortumorcharacteristics.
However,forwomenwithbreastcancerwhocarryadeleteriousBRCA1/2mutation,aCPMcanimprovebreast
cancersurvival[3,26].Thefollowingstudiesillustratethesefindings:
Inaretrospectiveanalysisof181patients,aCPMwasassociatedwitha48percentreductionindeathfrom
breastcancer(hazardratio[HR]0.52,95%CI0.290.93,p=0.03)[3].The20yearsurvivalratefor
BRCA1/2carriersundergoingaCPMwas88percentcomparedwitha66percentsurvivalrateforcarriers
treatedwithaunilateralmastectomy.
Aretrospectivereviewandmatchedanalysisof105womenwithbreastcancerandadeleteriousBRCA1/2
mutationundergoingaCPMhadagreater10yearsurvivalcomparedwithBRCA1/2carrierswithbreast
cancerwhodidnotundergoaCPM(n=593),(89versus71percent)[26].Afteradjustingforpotential
confounders,suchasoophorectomy,gradeandstageofcancer,andspecificgenewiththemutation,CPM
continuedtoprovideasurvivaladvantage(HR0.37,95%CI0.170.80,p=0.0008).
RiskofidentifyinganoccultbreastcancerTheriskoffindinganoccultinvasiveornoninvasivebreast
cancerintheCPMspecimen,notidentifiedonradiographicimaging(ie,mammogram,MRI),islowandreportedto
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beapproximately1to2percent[27,28].
Psychosocialeffects
Bodyimage,femininityAdversechangesinbodyimageincludingdiminishedfeelingsoffemininity,
sexualityandsexualsatisfaction,andselfesteemcanoccurfollowingaCPM[6,2932].Negativebodyimagewas
alsoassociatedwithhighpreoperativecancerdistress[29].Inasurveyofwomenwhohadundergone
contralateralprophylacticmastectomy,42percentstatedthattheirsenseofsexualitywasworsethanexpected,
and31percentfeltthattheirselfconsciousnessabouttheirappearancewasalsoworsethanexpected[19].
However,80percentreportedthattheywereextremelyconfidentintheirdecisiontohaveCPM,and90percent
wouldhavemadethesamedecisionagain[19].
ThepersonalsatisfactionfollowingaCPMisreportedlyhigh[32,33].Forexample,asurveyof583patientsfound
thatthemajority(83percent)ofwomenweresatisfiedwiththeCPM10yearsaftertheoperation,while8percent
wereneutraland9percentweredissatisfied[32].However,33percentweredissatisfiedwithbodyappearance,26
percenthadadversefeelingsoffemininity,and23percentreportedadversesexualrelationships.
However,suchahighlevelofsatisfactionmaybesecondarytocognitivedissonance,aphenomenondocumented
ininvalidatedpatientsatisfactionmeasurements,andrelevanttoautonomoussurgicaldecisionmakingwhenthe
decisionisdifficulttochange[2,3436].
QualityoflifeQualityofliferelatedmeasuresforwomenundergoingaCPMwerecomparabletowomenin
thegeneralpopulation.Inaprospectivestudyof60womenwithbreastcancerwhohadalsoundergoneaCPM,
mostpatientshadasatisfactoryhealthrelatedqualityoflifetwoyearsaftertheoperation,withnodifferencein
anxietyordepression[31].
OPERATIVEAPPROACHES
MastectomywithorwithoutreconstructionTypically,mostpatientsareadvisedtoundergothesametypeof
mastectomy(eg,skinsparing,conventional)thatisusedforthemastectomytotreatthebreastcancer.Thetype
ofmastectomyisdeterminedbythetumorcharacteristics,patientbodyhabitus,patientpreference,andsurgical
expertise.Thereisnoadverseimpactofimmediatereconstructioneitherinthedevelopmentordetectionoffuture
cancers[37].Reconstructionisdeterminedbytheuseofpostoperativeradiationtreatments,patientpreference,
andsurgeonexpertise.
Specificapproachestoperformingamastectomyandbreastreconstructionarediscussedseparately.(See
"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement"and"Breastreconstruction:
Preoperativeassessment".)
SentinellymphnodedissectionWhiletherearedifferencesofopinion,asentinelnodelymphnodedissection
isnotrequiredwhenperformingaCPM[27,28,38].Somehavearguedthattheriskofthisminimallyinvasive
procedureissmall,andwouldpreempttheneedforaxillaryevaluationifanoccultinvasivecancerwasfoundon
finalpathology[38].Others,however,arguethattheriskoffindingmetastaticdiseasewarrantingaxillarystaging
inpatientsundergoingprophylacticmastectomyislow,andthereforesentinelnodebiopsyinthesepatientscanbe
omitted[27].Randomizedtrialshavenotbeenperformedtoresolvetheissue.(See"Diagnosis,stagingandthe
roleofsentinellymphnodebiopsyinthenodalevaluationofbreastcancer"and"Sentinellymphnodebiopsyin
breastcancer:Techniques".)
SUMMARYANDRECOMMENDATIONS
Patientswithaunilateralsporadicbreastcancerareatamodestriskofdevelopinganinvasivecontralateral
breastcancer(CBC),andmostwomenneverwilldevelopacontralateralsecondprimarybreastcancer.(See
'Riskofcontralateralbreastcancer'above.)
ForbreastcancerpatientswhocarryaBRCA1orBRCA2mutation,theriskofacontralateralbreastcancer
isestimatedtorangefrom10to65percent.(See'Riskofcontralateralbreastcancer'above.)
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Womenwithbreastcancerandafamilyhistoryofbreastorovariancancerandwhoundergoacontralateral
prophylacticmastectomy(CPM)havea96percentreductioninriskofdevelopingacontralateralcancer.
(See'Contralateralprophylacticmastectomyriskreduction'above.)
WomenwithbreastcancerundergoingaCPMhaveagreaterthantwofoldincreasedriskofmajor
complications(eg,reoperation)comparedwithwomenundergoingaunilateralmastectomy.(See
'Postoperativemortalityandmorbidity'above.)
ACPMconfersanoverallsurvivalbenefitforwomenwhohavebreastcancerandcarryadeleterious
BRCA1orBRCA2mutation(see'Overallsurvival'above).Itislessclearifwomenwithsporadicbreast
cancer,particularlywomenoverage50years,haveasurvivalbenefitwithaCPM.
TheriskofidentifyinganoccultinvasivebreastcancerintheCPMspecimenisapproximately1to2percent.
(See'Riskofidentifyinganoccultbreastcancer'above.)
Typically,thesametypeofmastectomyisperformedforaCPMasforthemastectomytotreatthebreast
cancer.(See'Mastectomywithorwithoutreconstruction'aboveand"Mastectomy:Indications,types,and
concurrentaxillarylymphnodemanagement".)
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Topic94744Version4.0

Disclosures
Disclosures:AneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)Nothingtodisclose.RussellSBerman,MDNothingto
disclose.DonSDizon,MD,FACPNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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