Exploring the role of germline genetic testing in surgical decision making for early-stage invasive breast cancer: insights from a safety-net hospital.

Current guidelines recommend contralateral prophylactic mastectomy (CPM) for women with unilateral breast cancer who have pathogenic/likely pathogenic variants (PV) in high-risk genes, but not for those with variants of uncertain significance (VUS). However, VUS results can cause significant psychosocial distress, which may influence surgical decision-making. In safety-net settings, concerns about insurance coverage and additional social determinants of health may further impact CPM decisions. This study examines surgical trends among patients with early-stage invasive breast cancer who underwent genetic testing before surgery at a safety-net hospital in Dallas, Texas between 2012-2022. We performed a retrospective chart review of 300 early-stage breast cancer patients referred for genetic counseling, analyzing demographics, tumor characteristics, genetic testing results, and treatment. Descriptive statistics and regression analyses were performed. The cohort included 116 patients without mutations (control), 111 with VUS, and 73 with PV. 86.30% of PV patients, 30.63% of VUS patients, and 18.10% of the control group underwent CPM. Multivariate analysis identified PV (OR 26.35, 95% CI: 10.97-63.29, p < 0.0001), VUS (OR 2.35, 95% CI: 1.16-4.77, p = 0.0175), and age at diagnosis (OR 0.963, 95% CI: 0.934-0.993, p = 0.0168) as independent predictors of CPM. These findings suggest that factors beyond established guidelines may influence surgical decision-making, particularly for patients in safety-net hospital settings, underscoring the need for thorough provider and patient counseling.