Women who were diagnosed with breast cancer and had contralateral prophylactic mastectomy had only marginal improvement in psychosocial well-being, such as feeling confident and emotionally healthy, according to a study published in the Journal of Clinical Oncology.1 Those who also had breast reconstruction had higher breast satisfaction scores but lower physical and psychosocial well-being.
These findings coupled with studies demonstrating a survival benefit as low as 1% from contralateral prophylactic mastectomy could serve to stimulate patient-physician discussion about contralateral prophylactic mastectomy and promote a clearer understanding of its risks, benefits, and potential tradeoffs with and without breast reconstruction.
“I hope so,” the study’s lead author E. Shelley Hwang, MD, MPH, told The ASCO Post. Dr. Hwang is Chief of Breast Surgery at Duke University Comprehensive Cancer Center, Durham, North Carolina. Efforts to increase awareness about breast cancer and be vigilant about recommended screening have been very successful, she noted. “Now we need to work harder on giving women a realistic expectation of what their likely excellent outcome will be if they were diagnosed with cancer. Most women who are diagnosed with breast cancer don’t die of breast cancer; they die of something else,” Dr. Hwang said. “If we do a good job” in communicating that message, she added, “I think fewer women will be interested in what I feel in many instances is unnecessary surgery.”
Dr. Hwang advised being proactive in discussing the risks and benefits of contralateral prophylactic mastectomy and breast reconstruction with patients. “There are as many different ways of doing it as there are breast surgeons who have this conversation,” she said. “It is a natural part of the conversation, because women are going to be worried about recurrence of the cancer they have and future risks to the contralateral side. It is just a natural extension of the discussion that we are having about all the treatment options.”
“Some studies have tried to delve into why women choose to have contralateral prophylactic mastectomy, and almost always the top reason is to prevent any future risk of breast cancer,” Dr. Hwang noted, but that risk is often vastly overestimated. “That puts the burden of education on the providers, to make sure that patients understand that that risk is in fact quite low, and for most women who are diagnosed with invasive cancer, their risk of recurrence is much greater than their risk of having a new contralateral primary cancer. I always try to make sure that my patients understand that,” she stressed.
Unless a woman has a gene mutation that places her at significantly increased risk of a new cancer in the other breast, contralateral prophylactic mastectomy doesn’t prolong life, and our study shows that it doesn’t make for a notably better quality of life.— E. Shelley Hwang, MD, MPH
“Unless a woman has a gene mutation that places her at significantly increased risk of a new cancer in the other breast, contralateral prophylactic mastectomy doesn’t prolong life, and our study shows that it doesn’t make for a notably better quality of life,” Dr. Hwang said. Yet for many women faced with a diagnosis of breast cancer, “which is a life-altering event, any risk just seems to be too great,” she said, “and having the relief of not thinking about the other breast is actually the overriding concern.” As Dr. Hwang noted in an article in The New York Times, these women feel “they can’t rest until the other breast is done.”2 That’s when a thorough discussion of the risks and benefits of contralateral prophylactic mastectomy is most needed, because, Dr. Hwang said, “I always tell my patients you can’t have a do-over if you choose to have a bilateral mastectomy.”
Not a Gatekeeper
“This is based on personal philosophy rather than data, but I feel that my role is making sure that my patients understand the trade-offs, that I’ve tried to convey that information as best I can, and that they really understand what the data say. If all those things happen, and ideally they should, and patients still choose a contralateral prophylactic mastectomy, I certainly don’t think that I am the gatekeeper for this procedure. I don’t deny them a contralateral prophylactic mastectomy. I figure that they have made an informed decision, and part of making an informed decision, is that patients evaluate all the options and choose the one that is most consistent with their own values and beliefs. And if contralateral prophylactic mastectomy is that, and the patient is educated and understands the realistic estimates of contralateral breast cancer and still chooses to have it, then that is the right choice for them.”
But as the study shows, Dr. Hwang added, women who chose contralateral prophylactic mastectomy are “not overwhelmingly relieved, have a better life, or are happier. That is definitely not what the study shows, even though I think women project that it is all going to be true. If you ask them 4 years later, they don’t seem to be any significantly happier than the women who choose not to have contralateral prophylactic mastectomy.” ■
Disclosure: Dr. Hwang reported no potential conflicts of interest.
1. Hwang ES, Locklear TD, Rushing CN, et al: Patient-reported outcomes after choice for contralateral prophylactic mastectomy. J Clin Oncol. March 7, 2016 (early release online).
2. Rabin RC: No regrets after double mastectomy, but questions remain. The New York Times, March 21, 2016.