Patient decision-making styles influence consideration of contralateral prophylactic mastectomy

By Liz Meszaros, MDLinx
Published August 17, 2017

Key Takeaways

Over 50% of women with early-stage breast cancer have at least considered contralateral prophylactic mastectomy (CPM), and their approach to making big decisions—combined with their values—had an impact on which breast cancer treatments they considered, according to a study published in Cancer.

“The decision-making process is complicated. We found there are a lot of values that come into play,” said lead author Sarah T. Hawley, PhD, MPH, professor of internal medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI.

Using the SEER registries of Los Angeles and Georgia, researchers identified 2,578 women with early-stage breast cancer treated in 2013-2014, and surveyed them approximately 7 months after surgery. The primary outcome was strong versus less strong consideration of CPM. Researchers also assessed any associations between patient values and decisions styles and strong consideration of CPM using multivariate logistic regression.

In all, 25% of women reported a strong/very strong consideration of CPM, and 29% reported a moderate/weak consideration. Dr. Hawley and colleagues found that decision styles were varied, and the factors most valued by women at the time of their decisions included avoiding worry about recurrence (82), and reducing the need for more surgery (73%).

Upon multivariate analysis, strong consideration of CPM was significantly more likely in patients who preferred to make their own decisions, those who valued reduced worrying about recurrence, and those who valued avoiding radiation (P < 0.05). Patients who reported that they were more logical and those who valued keeping their breast did so less often.

“Fears about radiation are common, so it is very important to make sure women are fully informed before they make the decision to pursue much more aggressive surgery than they need,” said senior author Reshma Jagsi, MD, DPhil, professor and deputy chair of radiation oncology, Michigan Medicine. 

“We need to make sure women understand how far technology has advanced to make radiation treatment safe and tolerable. We also need to make sure women understand that even after mastectomy radiation might be recommended, if the cancer has certain features,” she added.

These findings suggest that CPM may be more likely to be driven by patient desire rather than physician recommendation.

“It goes against what the traditional shared decision-making model would suggest, which is when you involve people and inform them fully, most people would be inclined to choose less extensive treatment,” said Dr. Hawley.

Drs. Hawley and Jagsi and fellow authors, therefore, suggest that physicians consider patient values during the decision-making process, and have developed a decision tool to help patients prioritize their values and map them into potential treatment decisions.

“If physicians have feedback that a patient likes to make decisions a certain way, they can understand the patient’s emotional processing and help the patient make a decision that meets her needs physically and emotionally,” said Dr. Hawley.

She stressed that this may encompass educating patients about any misperceptions they may have of their risk of recurrence, which many overestimate. Further, many patients may not understand the impact of double mastectomy.

“A lot of these conversations around therapy – including extensive therapy that may not be truly beneficial in terms of survival – may come down to emotional values. Physicians need to help patients feel comfortable with treatment decisions within their underlying nature and values. This includes helping patients understand when less extensive treatment might be the right option. Patients need to feel secure in knowing that choice will give them their best chance at survival,” concluded Dr. Hawley.

This study was funded by the National Cancer Institute.

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