Expect Questions and Perhaps Unrealistic Expectations


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Treatment decisions are ultimately up to the individual. But physicians can frame options and educate patients in a way that incorporates psychology as well as statistics.

—Peggy Orenstein

A recent study reporting the absolute 20-year survival benefit from contralateral prophylactic mastectomy was less than 1% for women with stage I and II breast cancer without BRCA mutations runs counter to common perceptions about the risk of contralateral breast cancer among these women and the benefits of contralateral prophylactic mastectomy.1 (Earlier studies about perceptions of contralateral breast cancer and contralateral prophylactic mastectomy are referenced in the current study.)

The less than 1% survival benefit was found among all subgroups studied—by age, estrogen receptor status, and cancer stage—although contralateral prophylactic mastectomy was more beneficial among younger women, those with stage I disease, and those with estrogen receptor–negative breast cancer, according to the report, published in the Journal of the National Cancer Institute.1 The stated aim of the study was “to provide projected long-term survival information by using a stimulated Markov model for physicians and their patients when discussing breast cancer risk-reduction strategies.”

In an interview with The ASCO Post, study coauthor Todd M. Tuttle, MD, MS, noted that those risk-reduction strategies could include standard follow-up and tamoxifen or an aromatase inhibitor. “There is a growing body of research looking at alternative ways to reduce risk as well by diet and exercise,” he added, although “there are not really strong data on that yet.” Dr. Tuttle is Chief of the Division of Surgical Oncology at the University of Minnesota in Minneapolis and Medical Director of the University of Minnesota Breast Center.

More and Better Information

The article concludes that the “survival estimates derived from our model may be useful for physicians and breast cancer patients to arrive at evidence-based informed decisions regarding [contralateral prophylactic mastectomy].” While the study’s impact cannot yet be gauged, Dr. Tuttle said, “What I hope it does is at least provides women with better information.”

Information about the study appeared in reports in both the medical and popular press, including a New York Times Sunday Review opinion article that included comments from Dr. Tuttle. In that opinion article, titled “The Wrong Approach to Breast Cancer,” New York Times Magazine contributing writer Peggy Orenstein discussed the study and personal experiences with breast cancer, writing, “Treatment decisions are ultimately up to the individual. But physicians can frame options and educate patients in a way that incorporates psychology as well as statistics. Beyond that, doctors are not obliged to provide treatment that is not truly necessary.” 2

The study report noted that “the use of accurate and easily understood decision aids may reverse some of the mastectomy trends recently observed in the United States.” Still in the development phase and intended to be used in addition to patient-physician discussions, those decision aids could include online tools to provide women with information on what they can expect from risk of recurrence, risk of death, risk of complications, and side effects from having these different procedures, Dr. Tuttle explained.

Other Potential Benefits

The JNCI authors acknowledged that survival “is only one potential benefit of a cancer risk-reduction strategy; effects on cancer-related anxiety, cosmesis, and self-image are also important in decision-making processes. For some women, the negative impact of contralateral prophylactic mastectomy on quality of life may outweigh a potential survival benefit. For others who are very anxious about [contralateral breast cancer], [contralateral prophylactic mastectomy] may result in a psychological benefit even if survival benefits are minimal.”

An accompanying editorial points out, “The balance between harm and benefit depends on the patient’s preferences and highlights the importance of capturing the patient’s values and expectations before considering [contralateral prophylactic mastectomy].”

References

1. Portschy PR, Kuntz KM, Tuttle TM: Survival outcomes after contralateral prophylactic mastectomy: A decision analysis. J Natl Cancer Inst 106(8):dju160, 2014.

2. Orenstein P: The wrong approach to breast cancer. New York Times, July 26, 2014.

3. Pauker SG, Alseiari M: How big is big enough? Thinking about contralateral prophylactic mastectomy. J Natl Cancer Inst 106(8):dju175, 2014.


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Survival Benefit of Contralateral Prophylactic Mastectomy Less Than 1% at 20 Years, but Numbers of Procedures Have Increased

For women with stage I and II breast cancer without BRCA mutations, the absolute 20-year survival benefit from contralateral prophylactic mastectomy was less than 1%, regardless of age, estrogen receptor status, and cancer stage, according to a decision analysis study using a Markov model to...


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