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Contralateral prophylactic mastectomy often used unnecessarily
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Fear of recurrence drove many women with breast cancer to consider or undergo contralateral prophylactic mastectomy even when they were not at significant risk for contralateral occurrence, according to an analysis of SEER data.
“Women appear to be using worry over cancer recurrence to choose contralateral prophylactic mastectomy,” researcher Sarah Hawley, PhD, MPH, associate professor of internal medicine at the University of Michigan Medical School, said in a press release. “This does not make sense, because having a non-affected breast removed will not reduce the risk of recurrence in the affected breast. For women who do not have a strong family history or a genetic finding, we would argue it's probably not appropriate to get the unaffected breast removed.”
Sarah Hawley
Hawley and colleagues conducted a longitudinal survey of 1,536 women who were newly diagnosed with breast cancer and were registered in the 2005 to 2007 Detroit and Los Angeles SEER registry. Follow-up surveys were conducted 4 years later.
The analytic sample included 1,447 women, 18.9% of whom strongly considered contralateral prophylactic mastectomy and 7.6% of whom underwent the procedure.
Many women who strongly considered contralateral mastectomy received it (32.2%), whereas 45.8% underwent unilateral mastectomy and 22.8% underwent breast conversation surgery.
A majority of women who underwent contralateral prophylactic mastectomy did not have major genetic or familial risk factors for contralateral occurrence (68.9%), and most women indicated worry about recurrence affected their decision (78.1%).
Researchers determined several factors were significantly associated with the decision to undergo contralateral prophylactic mastectomy rather than unilateral mastectomy or breast-conserving surgery. Those factors included receipt of positive genetic testing (RR ratio=10.48; 95% CI, 3.61-30.48), a strong family history of breast or ovarian cancers (RR ratio=5.19; 95% CI, 2.34-11.56), receipt of MRI (RR ratio=2.07; 95% CI, 1.21-3.52), a higher level of education (RR ratio=5.04; 95% CI, 2.37-10.71) and high levels of worry about recurrence (RR ratio=2.81; 95% CI, 1.14-6.88).
In order to address the possibility of overtreatment, shared decision making is necessary before patients undergo contralateral prophylactic mastectomy, Shoshana M. Rosenberg, ScD, MPH and Ann H. Partridge, MD, MPH, both of Dana-Farber Cancer Institute, wrote in an accompanying editorial.
“Not only should pros and cons of different treatment options be communicated, but there needs to be consideration of the patient’s personal circumstances and perceptions, all the while addressing anxiety and concerns about breast cancer recurrence and new primary disease (and the distinction between the two),” Rosenberg and Partridge wrote. “Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike.”
For more information:
- Rosenberg SM. JAMA Surg. 2014;doi:10.1001/jamasurg.2013.5713.
- Hawley ST. JAMA Surg. 2014;doi:10.1001/jamasurg.2013.5689.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Todd M. Tuttle, MD, MS
The use of contralateral prophylactic mastectomy (CPM) has markedly increased in the United States over the past 15 years. In this population-based survey study, Hawley and colleagues reported that the majority (68.9%) of patients who underwent CPM had no major genetic or familial risk factors for contralateral breast cancer. Other recent survey studies have demonstrated that women with unilateral breast cancer substantially overestimate their risk for contralateral breast cancer. For women without BRCA mutations, the annual risk for contralateral breast cancer is only about 0.4% to 0.5% per year, with a cumulative 10-year risk of 4% to 5%. The mortality of the known breast cancer exceeds the risk for contralateral breast cancer for most women.
In addition to overestimating the risk of contralateral breast cancer, many patients with breast cancer overestimate the benefit of CPM. In another survey study by Rosenberg and colleagues, 94% of women who underwent CPM cited “desire to improve my survival/extend my life” as an extremely or very important reason for CPM. However, the 20-year survival benefit of CPM is less than 1% for patients without BRCA mutations. So, overestimation of contralateral breast cancer risk and unrealistic expectations of CPM may be contributing to this trend of more aggressive breast cancer surgery. The development and implementation of decision aides are critically important to provide patients with accurate and easily understood information. Specifically, physicians should effectively communicate the actual risk for contralateral breast cancer, the potential complications of CPM, the likelihood of distant metastases from the index breast cancer and alternatives to CPM. Perhaps, with improved patient education, the CPM trends in the United States will plateau or be reversed.
For more information:
- Abbott E. Ann Surg Oncol. 2011;18:3129-3136.
- Portschy PR. J Natl Cancer Inst. 2014;doi:10.1093/jnci/dju160.
- Rosenberg SM. Ann Intern Med. 2013;159:373-381.
- Tuttle TM. J Clin Oncol. 2007;25:5203-5209.
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