Fear Drives Breast Cancer Surgery Decisions

The decision to undergo contralateral prophylactic mastectomy is often driven by fear of recurrence rather than clinical risk

medwireNews: Most breast cancer patients who choose contralateral prophylactic mastectomy (CPM) do not have a clinical indication for the extensive procedure, US researchers have found.

Just 31.1% of the patients included in the study who underwent CPM had a BRCA1 or BRCA2 mutation or another known genetic indicator, or had a strong family history of breast and ovarian cancer, report Sarah Hawley, from the University of Michigan Medical School in Ann Arbor, and co-authors.

Indeed, 20.8% of the patients choosing CPM had a negative genetic test result, while 80.0% had the procedure due to fears of recurrence, despite no evidence that removing the healthy breast will prolong survival, the team reports in JAMA Surgery.

The study of 1447 US women aged 20 to 79 years old and living in Detroit, Illinois or Los Angeles, California, showed that 18.9% of patients strongly considered CPM, with 57.6% of patients eventually choosing breast-conserving surgery (BCS), 34.4% unilateral mastectomy and 7.9% CPM. The majority (85.9%) of CPM patients underwent reconstruction.

Multivariate analysis showed that women were significantly more likely to choose CPM, relative to unilateral mastectomy or BCS, if they had a positive genetic test (relative risk ratio [RRR]=10.48 and 19.10, respectively) and had a strong family history of breast or ovarian cancer (RRR=5.19 and 4.24).

In addition, CPM was more likely to be chosen than unilateral mastectomy or BCS if the patient had received magnetic resonance imaging (MRI; RRR=2.07 and 2.14, respectively), had a higher level of education (RRR=5.04 and 4.38) and had a greater worry of recurrence (RRR=2.81 and 4.24).

“[O]ur findings that CPM was strongly associated with higher educational attainment suggests that improved knowledge may not be sufficient to address patient factors, such as worry about recurrence, motivating strong consideration of the procedure”, Sarah Hawley et al say.

“Furthermore, the association found between diagnostic MRI and receipt of CPM indicates a need to consider strategies for educating both patients and clinicians about the impact of extensive testing on treatment decision making.”

In an accompanying comment, Shoshana Rosenberg and Ann Partridge, from the Dana-Farber Cancer Institute in Boston, Massachusetts, USA, observe: “While CPM might be considered overtreating women without clinical indications, it might still be the right choice for some women for risk reduction, cosmetic, and/or emotional reasons.”

They emphasise: “Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike.”

References

Hawley S, Jagsi R, Morrow M, et al. Social and clinical determinants of contralateral prophylactic mastectomy. JAMA Surg 2014; Published online 21 May. doi:10.1001/jamasurg.2013.5689

Rosenberg S, Partridge A. Contralateral Prophylactic Mastecotmy. An opportunity for shared decision making. JAMA Surg 2014; Published online 21 May. doi:10.1001/jamasurg.2013.5713

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