Choice to undergo double mastectomy rises among women with early breast cancer

Many women are opting to have contralateral prophylactic mastectomies (CPMs), even when the procedure is not indicated, according to results from a population-based survey of patients with early-stage breast cancer, published in JAMA Surgery. Although many surveyed respondents reported incomplete or no discussion with their surgeons, rates of CPM in those who received a surgical recommendation against it were low.

Results from this large study revealed that many patients consider CPM, but their knowledge about the procedure is low, and discussions with their surgeon may not occur.

“That 1 in 6 breast cancer patients chose bilateral mastectomy is really striking. We knew it was increasing, but I don’t think many of us realized just how frequent this is,” noted author Reshma Jagsi, MD, DPhil, professor and deputy chair of radiation oncology, University of Michigan, Ann Arbor, MI.

Dr. Jagsi and fellow researchers sought to assess patient motivations, knowledge, and decisions in a large sample of patients undergoing recent breast cancer treatment, and also sought to determine the impact of surgeons’ recommendations on their choices.

Between July 2013 and September 2014, they sent surveys to 3,631 women with newly diagnosed, unilateral stage 0, I, or II breast cancer identified via the population-based Surveillance Epidemiology and End Results (SEER) registries of Los Angeles County and Georgia. Researchers recorded and analyzed data regarding patients’ surgical decisions, motivations behind those decisions, and knowledge in making these decisions to identify factors associated with CPM compared with all other treatments combined, CMP compared with unilateral mastectomy (UM), and CPM compared with breast-conserving surgery (BCS). They also assessed any associations between surgeon recommendations and undergoing CPM.

In all, 2,578 women (mean age: 61.8 years) responded to the survey (71.0%), of whom 2,402 did not have bilateral disease and for whom surgery type was known. Of these respondents, a full 43.9% considered CPM, of whom 24.8% considered it strongly or very strongly. Yet only 38.1% were aware that CPM does not improve survival for all women with breast cancer.

A full 61.6% underwent BCS, 21.2% UM, and 17.3% CPM.

Upon multivariate analysis, researchers found that the factors associated with undergoing CPM included young age (per 5-year increase: OR: 0.71; 95% CI: 0.65-0.77), white race (white vs. black: OR: 0.50; 95% CI: 0.34-0.74), higher level of education (OR: 1.69; 95% CI: 1.20-2.40), family history (OOR: 1.63; 95% CI: 1.22-2.17), and having private insurance (Medicaid vs private insurance: OR: 0.47; 95% CI: 0.28-0.79).

A full 65.5% of patients (n=1,569) did not have high genetic risk or carry an identified mutation, of whom 39.3% received a surgeon recommendation against CPM. Of these, only 1.9% had CPM. Among the 46.8% of women who reported receiving no surgeon recommendation for or against CPM, 19.0% underwent CPM.

Researchers, therefore, highlighted the need for more effective and complete physician-patient discussion and communications about CPM to reduce possible overtreatment.

“As physicians, we want to be respectful of our patients’ preferences and values. We don’t want to alienate patients who are already in a stressful situation. We want them to trust us. When a patient comes in saying she has already decided on double mastectomy, it can be challenging to strike that balance between respecting her preferences and adequately conveying why the medical community in general doesn’t think it’s necessary,” she added.

“At a time when emotions are running high, it’s not surprising that newly diagnosed breast cancer patients might find it difficult to absorb this complex information. It seems logical that more aggressive surgery should be better at fighting disease—but that’s not how breast cancer works. It’s a real communication challenge,” Dr. Jagsi concluded.