Delayed Contralateral Prophylactic Mastectomy: A Tertiary Centre Experience

Introduction: Reasons for requesting CPM include prevention of recurrence, peace of mind and moving on after breast cancer. Some women seek CPM as a delayed procedure but factors influencing this are poorly understood. There are challenges for Breast Reconstruction (BR) after delayed CPM relating to previous ipsilateral reconstructive procedures, adjuvant therapies such as radiotherapy, and comorbidities.

Methods: A retrospective analysis examined breast cancer patients undergoing CPM with or without BR at a single tertiary referral center between January 2009 and December 2019. Patients undergoing delayed CPM were identified. Data were collected on demographics, timing and type of surgery, neoadjuvant/adjuvant treatments and complications based on the Clavien-Dindo classification. A cross-sectional survey based on validated questionnaires (5-point Likert scale) explored patients’ decision-making process in terms of timing of CPM and any BR.

Results: A total of 123 patients with unilateral breast cancer underwent CPM with 39 (32.5%) of them as delayed procedures (with respect to therapeutic mastectomy) with or without BR. Of these 39 delayed CPM patients 12 (31%) had immediate BR at the time of cognate mastectomy, 22 (56%) had bilateral BR simultaneously with the delayed CPM, 3 (8%) had bilateral delayed BR following CPM whilst 2 (5%) had no reconstruction at all. Mean patient age was 52 years (range 24-73) and the average interval between initial and delayed mastectomy was 2.67 years (range 0-22). The majority of reconstructions where patients had underwent implant-based (n=28) rather than exclusively autologous reconstruction (n=9). Complications (major) occurred in 8 patients with unilateral BR compared with 5 of patients with bilateral immediate BR and 3 of patients undergoing bilateral delayed BR.

The response rate amongst patients receiving questionnaires (n=33) was 22/33 (66%). The most common reason for delayed CPM was to complete all cancer treatments (including radiotherapy) before surgery on the unaffected breast (score 2.91).

Conclusion: Factors for delayed CPM are patient-driven with few women spontaneously changing their mind having initially decided against immediate CPM for reasons also including surgical duration. CPM should be offered as a potentially delayed option with informed discussion of risks and benefits.