The Asco Post

Experts Discuss Challenges in Counseling Patients About Contralateral Prophylactic Mastectomy

By Jo Cavallo
Posted: 8/2/2013 2:04:12 PM
Last Updated: 8/5/2013 4:12:10 PM

Key Points:
  • The rate of contralateral prophylactic mastectomy for unilateral breast cancer increased from 39 to 207 per 1,000 mastectomies between 1998 and 2008. 
  • Contralateral prophylactic mastectomies should be reserved for women at high risk for second primary breast cancer. However, few women who undergo contralateral prophylactic mastectomy are in the recognized high-risk group.

Many factors play into why women diagnosed with breast cancer often choose overly aggressive treatment even when there is little evidence to show clinical benefit: the shock and fear of suddenly being confronted with a major health threat, the impression of having to make treatment decisions quickly, fear of cancer recurrence, and the desire to put the cancer diagnosis behind them. Wishing to help patients achieve peace of mind, “physicians may be prone to acquiesce to a patient’s preference for management plans with more aggressive treatments. For example, a patient’s expression of fear about recurrence or desire to avoid regret later may lead to a decision to perform more aggressive surgery or administer chemotherapy in patients with uncertain clinical indications,” wrote Steven J. Katz, MD, MPH, Departments of Medicine and Health Management and Policy at the University of Michigan, and Monica Morrow, MD, Department of Surgery at Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University. Their Viewpoint appears in the Journal of the American Medical Association.

Greater Clarity in Clinical Logic

The authors cite the increase in the number of contralateral prophylactic mastectomies performed on patients with unilateral breast cancer as an example of the need for greater clarity in the clinical logic of prescribing a more aggressive intervention to address patients’ reactions to their management plans. Using statistics from the Nationwide Inpatient Sample, the authors found that the rate of contralateral prophylactic mastectomy for unilateral breast cancer increased from 39 to 207 per 1,000 mastectomies between 1998 and 2008, representing about 20,000 patients in 2008. In contrast, wrote the authors, the rate of bilateral prophylactic mastectomy performed in women without a breast cancer diagnosis increased from 5 to 18 per 1,000 during the same period.

Contralateral prophylactic mastectomies should be reserved for women at high risk for second primary breast cancer, for example, women with BRCA-positive gene mutations. However, few women who undergo contralateral prophylactic mastectomy are in the recognized high-risk group, noted the authors.

Addressing Peace of Mind Without Putting Patients at Risk

Compared with lumpectomy, contralateral prophylactic mastectomy (usually accompanied by breast reconstruction) entails a much longer surgical time and recovery and increases the risk for long-term complications. Therefore, surgeons are growing increasingly uncomfortable with performing the more aggressive surgery in low- or average-risk patients who are candidates for a more breast-conserving approach.

Surgeons may rationalize their willingness to perform contralateral prophylactic mastectomy because they believe the operation may improve long-term quality of life. Another reason they acquiesce to their patient’s decisions is they may face adverse consequences in their practice, including loss of that patient to another surgeon. In addition, said the authors, “in an atmosphere of patient-centered care, refusing a patient request for [contralateral prophylactic mastectomy] is difficult.”

Ensuring that patients understand the risks and benefits of more aggressive surgical treatment, counseling them on their individual risk for second primary cancer, encouraging patients to take more time to consider their treatment options, and examining practice incentives that may foster overtreatment in cancer may help address the issue of peace of mind in patients facing breast cancer without putting them “at risk of unnecessary morbidity and burden of treatment,” said the authors.

The authors reported no potential conflicts of interest.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.

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