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Women considering double mastectomies satisfied with surgery choices
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Women who considered contralateral prophylactic mastectomies following a new diagnosis of unilateral breast cancer were satisfied with their decisions regarding surgery, even if their surgeons recommended against the procedure, according to a study published in JAMA Surgery.
“We hypothesized that patients whose first surgeons recommended against contralateral prophylactic mastectomy might report less satisfaction, and might be more likely to seek second opinions and pursue surgery by a second surgeon,” Steven J. Katz, MD, MPH, professor of medicine and of health management and policy at University of Michigan, said in a press release. “But in this study, an initial recommendation against contralateral prophylactic mastectomy had little impact on overall satisfaction with treatment or on decisions to pursue or act on a second opinion.”
According to a 2015 study by Albornoz and colleagues, there has been a 14% annual increase since 2005 in contralateral prophylactic mastectomy, also called double or bilateral mastectomy, although it has not been shown to improve survival in women with stage 0 to stage II unilateral breast cancer. Current clinical guidelines suggest that bilateral mastectomy should be discouraged in patients who do not have an elevated risk for second primary cancers based on family history and results of genetic tests.
Researchers evaluated survey responses from 1,140 women (mean age, 56 years) newly diagnosed with stage 0 to stage II unilateral breast cancer who had considered bilateral mastectomy. More than half (56.1%) of the women were aged younger than 60 years, 25.3% completed high school or less, and 44.1% were nonwhite.
More than half of the women surveyed (57.5%) strongly or very strongly — as opposed to weakly or moderately — considered contralateral prophylactic mastectomy.
Ultimately, 40.5% underwent breast-conserving therapy; 22% underwent unilateral mastectomy, including 41.4% who also underwent breast reconstruction; and 38.2% chose bilateral mastectomy, 76.6% with breast reconstruction.
More than one-quarter (26.7%; n = 304) of the women surveyed reported their first surgeon recommended against contralateral prophylactic mastectomy, and 30.1% (n = 343) reported they had no substantial discussion with their surgeon regarding the procedure.
Of women recommended against contralateral prophylactic mastectomy, only 6.1% proceeded with the procedure, compared with 57.5% of women who received no recommendation against it (P < .01).
Dissatisfaction with the decision to have surgery was uncommon (7.6%; n = 130).
One-fifth of patients (20.6%; n = 304) sought a second opinion and 9.8% (n = 158) had surgery performed by a second surgeon.
Dissatisfaction was very low (3.9%; n = 42) among patients whose surgeons discussed but did not recommend against bilateral mastectomy. Dissatisfaction was higher (14.5%; n = 37) for those whose surgeons recommended against contralateral prophylactic mastectomy with no substantial discussion.
Additionally, women who received a recommendation against contralateral prophylactic mastectomy were not more likely to seek a second opinion (17.1% vs. 15.1%) or receive surgery by a second surgeon (7.9% vs. 8.3%) compared with women who did not receive a recommendation against the procedure.
“The increased attention to and preference for contralateral prophylactic mastectomy among patients for whom it is not a clinical imperative is a relatively recent phenomenon,” Katz said. “It’s one of many considerations on the minds of patients we know are understandably anxious and who may feel they need to make treatment decisions quickly after diagnosis.”
In their initial consultations with patients, physicians need to stress all available options and the importance of examining which best fits the needs of the patient, Katz said.
“It’s so important in those initial consultations that the patient and the surgeon feel free to discuss all of the options and work together to determine the best path forward.” Katz said. – by Chuck Gormley
Disclosure: NCI funded this study. Researchers report no relevant financial disclosures.
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