Physician–patient communication essential to ensure informed decision about contralateral prophylactic mastectomy

A survey of 2,000 women with breast cancer revealed approximately half of them considered undergoing contralateral prophylactic mastectomy.

That statistic is alarming to experts, who contend the majority of women who undergo the procedure are not at high risk for contralateral breast cancer. They also point to a lack of data showing a survival benefit with contralateral prophylactic mastectomy.

“Our finding that so many women are receiving much more extensive surgery than needed to treat their disease is striking,” researcher Reshma Jagsi, MD, DPhil, associate professor of radiation oncology at University of Michigan Medical School, said in a press release.

“Women diagnosed with breast cancer are naturally eager to do everything in their power to fight the disease,” Jagsi said. “So many of my patients tell me that they just want to do everything they can to be there for their kids. It is up to us, as doctors, to make sure they understand which treatments are really going to do that, and which actions might seem heroic but are actually not expected to improve the outcomes for a typical woman with early-stage breast cancer.”

Shoshana Rosenberg

HemOnc Today spoke with Shoshana Rosenberg, ScD, MPH, an instructor in the department of medical oncology at Dana-Farber Cancer Institute, about why contralateral prophylactic mastectomy has become more common and how clinicians should discuss this option with their patients.

Question: The phrase ‘epidemic’ has been used to describe the increase in women who opt to undergo contralateral prophylactic mastectomy. Is this an appropriate term?

Answer: I think it is fair to use this term. The rates of contralateral prophylactic mastectomy have dramatically increased in such a short period time. This is a relatively recent trend, which has only been documented within the past decade or decade and a half.

Q: Can you quantify the trend?

A: A paper published in 2014 in JAMA included data from an analysis led by a team at Stanford University that examined trends in the California Cancer Registry between 1998 and 2011. This analysis included more than 189,000 women. The researchers documented an increase in bilateral mastectomy in the overall population from 2% in 1998 to 12.3% in 2011. This equates to about a 14% increase per year. Among women aged younger than 40 years, they documented a rate increase from 3.6% to 33%. This was a huge increase. Other papers have demonstrated similar increased trends.

Q: Why is this happening?

A: There are a lot of reasons. One of the clinical factors has to do with the advancements in reconstruction techniques. There has also been a similar increase in the use of MRI at the time of diagnosis, and MRIs often pick up abnormalities that are not cancer. A woman may have a result that ends up not being cancer from the MRI, but they do not want to have to worry about the possibility of it being cancer so the patient decides to undergo contralateral prophylactic mastectomy. Another reason is there has been a lot of media attention surrounding bilateral mastectomy. Angelina Jolie is one example. She did not have breast cancer, but she did have a genetic mutation and was, therefore, at very high risk. There have been other celebrities like Sandra Lee who did have breast cancer and were very public about having a contralateral prophylactic mastectomy.

Q: Should efforts intensify to reverse this trend?

A: I think it is important to step back and frame this controversy in the context that there is no right or wrong decision about surgery. It is an individual decision that is made by a woman who has been diagnosed with breast cancer. Every woman has their own individual circumstances. We have a responsibility to ensure that women who are making decisions about surgery are informed and that they are choosing their procedure based upon an accurate understanding of the risks and benefits rather than making the choice for the wrong reasons. Some women cite peace of mind for the reason that they opt to undergo more aggressive surgery, and it is important for women to understand that while removing their contralateral breast reduces their risk of contralateral breast cancer, for most women this risk is not very high. So, if they are doing this for peace of mind, it is important for them to understand that having a contralateral prophylactic mastectomy does not affect their risk for developing metastatic recurrence.

Q: Why do some see this trend in a negative light?

A: I think the dominant issue is because of the medical principle of “First, do no harm.” From a medical perspective, contralateral prophylactic mastectomy in women who are not at otherwise high risk is really medically unnecessary because it does not improve survival. Whether these women have a lumpectomy or mastectomy, the survival rate is going to be the same. Women may be choosing this surgery for the wrong reasons, because more surgery isn’t necessarily better.

Q: What should the clinical community do?

A: This is tricky, because there is the fundamental tension of do no harm, but at the same time we want patients to feel empowered and take control of their medical decision. From a provider perspective, there is a need to ensure that women are making informed decisions. Doctors and other providers can play a part in really ensuring that women accurately understand the risks and benefits of all types of surgery. One way to do this is to improve communication between doctors and patients. The second part of this is that providers have to acknowledge that this is a stressful time for patients and really need to be there for them and help support women from an emotional standpoint.

Q: What is your advice to the patient considering contralateral prophylactic mastectomy?

A: It is really important to convey that there is no right or wrong decision. The decision about surgery really has to be made in consideration of patient preferences while at the same time ensuring patients are fully informed about their decision and made in a setting where their anxiety, needs, concerns, and short- and long-term expectations are addressed. – by Jennifer Southall

For more information:

Shoshana Rosenberg, ScD, MPH, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02215; email: shoshana_rosenberg@dfci.harvard.edu.

Disclosure: Rosenberg reports no relevant financial disclosures.