Physician–Patient Communication Key For Appropriate Contralateral Prophylactic Mastectomy Decision

Surgeon recommendations play a crucial part in breast cancer patients’ decisions about contralateral prophylactic mastectomy

medwireNews: Although the use of contralateral prophylactic mastectomy (CPM) is “substantial” among patients with early-stage breast cancer who lack clinical indications for the procedure, physician recommendation against CPM can reduce uptake, find US researchers.

They write in JAMA Surgery that the results “should motivate surgeons to broach these difficult conversations with their patients, to make their recommendations clear, and to promote patients’ peace of mind by emphasizing how other treatments complement surgery to reduce the risk of both tumor recurrence and subsequent cancer development.”

Using the Los Angeles County and Georgia registries of the Surveillance, Epidemiology, and End Results Program database, the team identified and surveyed 2402 women diagnosed with unilateral, stage 0–II breast cancer for whom the surgery type was known.

Overall 43.9% of participants considered CPM, with 24.8% considering it very strongly or strongly.

Just over half (52.0%) of those at high risk of developing a second primary breast cancer considered CPM and just over a quarter (26.4%) underwent the procedure, whereas the corresponding rates among patients with an average risk were 40.9% and 14.2%, report lead author Reshma Jagsi, from the University of Michigan in Ann Arbor, and colleagues.

Referring to the rates for average-risk women, they comment: “This strong patient interest in CPM and the substantial use of this aggressive surgical procedure by patients who are unlikely to develop a second breast cancer is sobering.”

However, the study authors noted a “strong influence” of physician recommendation on CPM receipt.

Among women considered at average risk (ie, those without an elevated genetic risk or a known deleterious mutation), 39.3% reported that their surgeon recommended against CPM whereas 46.8% received no recommendation. The corresponding rates of CPM receipt were 1.9% and 19.0%, leading the team to conclude: “More effective physician-patient communication about CPM is needed to reduce potential overtreatment.”

Writing in an accompanying comment, Oluwadamilola Fayanju and E Shelley Hwang, both from Duke University Medical Center in Durham, North Carolina, USA, emphasize the importance of weighing “the balance between respecting patients’ preferences and leaving them with the long-term consequences associated with an ‘unnecessary’ operation.”

They continue: “Although CPM is not associated with improved survival, it reduces the risk of contralateral breast cancer, and the significance of this fact to some patients should not be minimized.”

The commentators conclude that “[f]or many women who choose CPM, the peace of mind associated with a reduced—albeit not eliminated—likelihood of subsequent cancer justifies the additional surgery and the potential attendant complications, even if the avoided cancer might not have actually shortened their lives.”

References

Jagsi R, Hawley ST, Griffith KA, et al. Contralateral prophylactic mastectomy decisions in a population-based sample of patients with early-stage breast cancer. JAMA Surg; Advance online publication 21 December 2016. doi:10.1001/jamasurg.2016.4749

Fayanju OM, Hwang ES. Contralateral prophylactic mastectomy. Aligning patient preferences and provider recommendations. JAMA Surg; Advance online publication 21 December 2016. doi:10.1001/jamasurg.2016.4750

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