Contralateral prophylactic mastectomy in male breast cancer: where do we stand?

Antonella Sciarra1, Carlo Buonerba*,2,3,4, Giuseppe Di Lorenzo2,4,5 & Luca Scafuri2,4,6 1Department of Experimental Medicine, University of Campania ’Luigi Vanvitelli’, Naples, NA, Italy 2Oncology Unit, Hospital ’Andrea Tortora’, ASL Salerno, Pagani, Italy 3Centro di Referenza Nazionale per l’Analisi e Studio di Correlazione tra Ambiente, Animale e Uomo, Istituto Zooprofilattico Sperimentale del Mezzogiorno, Portici, Italy 4Associazione O.R.A., Somma Vesuviana, Naples, Italy 5Department of Medicine & Health Science, University of Molise, Campobasso, Italy 6Department of Clinical Medicine & Surgery, University of Naples ’Federico II’, Naples, Italy *Author for correspondence: carbuone@hotmail.com

its cost and disadvantages [9]. Currently, presence of a BRCA mutation represents the strongest indication for CPM in both females and males. In a cross-sectional survey involving 1226 physicians among medical and radiation oncologists as well as plastic and general surgeons, 92% of participants recommended CPM in those with a mutated BRCA gene [10]. While indication for CPM in presence of a BRCA mutation is established, MBC patients who are at an 'average' risk of recurrence face the dilemma of undergoing CPM or not. In this regard, a significant tool has been recently made available by Li et al. who developed and published a nomogram capable of estimating the risk of contralateral breast cancer in male patients [11]. The researchers retrospectively analyzed the medical information of 4405 MBC patients treated with unilateral mastectomy or CPM from 1998 to 2015 retrieved from the Surveillance, Epidemiology and End Results database. The proposed nomogram was constructed to estimate the 3-, 5-and 8-year probabilities of breast cancer-specific death. The study cohort comprised 4197 patients treated with unilateral mastectomy and 208 patients treated with CPM, who were followed-up for a median of 63-months median follow-up. The authors found that the simultaneous evaluation of xi parameters including CPM, marital status, T-stage, N-stage, histology and tumor grade allowed the prediction of the pre-established outcomes with a C-index 0.75 (95% CI: 0.73-0.77) in the training cohort and 0.73 (95% CI: 0.71-0.74) in the internal validation group [11].
In this Editorial, we have reviewed useful evidence to underline the potential role of CPM in patients with MBC and the uncertainties of the associated benefits, which generates a challenging situation for both the patient and the physician. While evaluation of known risk factors, such as presence of BRCA mutation or any of the other conditions reviewed above, is surely important, the possibility of providing the exact expected increase in the chances of survival associated with CPM is of great value in the context of common clinical practice. In practical terms, we propose that in men with a BRCA mutation, CPM should always be discussed with the patient, with benefits outweighing risks in the majority of cases. In those who do not harbor a BRCA mutation, the use of the cited nomogram appears to provide valuable information to be discussed with the patient on an individual basis. For instance, in a patient with a risk of breast cancer death at 8 years of 30%, CPM can yield a considerable risk reduction in absolute terms ( ∼ = 10%), which becomes trivial in men who have a risk of 5% without CPM because of the favorable characteristics of the disease. Randomized Phase III trials are required, specifically designed to randomize men who have completed the standard course of treatment for breast cancer, to CPM versus observation. Men with wild-type BRCA and men with an estimated risk of breast cancer-related death at 5 years > = 20% could be included. Although a large sample size would be needed, which may be accomplished only with an international effort, such a trial would represent a unique opportunity to establish the optimal indication for CPM.
Financial & competing interests disclosure C Buonerba is a member of the Future Science OA Editorial Board. They were not involved in any editorial decisions related to the publication of this article. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

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