21 December 2016
A study published in JAMA Surgery found that in women with early stage breast cancer, a surgeon recommendation against removal of the unaffected, healthy breast (known as a contralateral prophylactic mastectomy or CPM) often led to the patient not undergoing that procedure. However, if the surgeon did not make a specific recommendation for or against the procedure, the patient often did undergo CPM.
Over the past 10-15 years, the rates of CPM have been increasing in patients with early stage breast cancer. While a woman may have valid reasons for this decision, the increasing CPM rates are concerning for many reasons. CPM does not improve outcomes or survival from breast cancer, and complications can be significant. Earlier this year, the American Society of Breast Surgeons (ASBrS) published a consensus statement recommending against the routine use of CPM in average risk women. The statement also advised physicians to make a specific recommendation for or against CPM when counseling patients.
CPM has been associated with younger age, receipt of genetic testing (even with negative results), family history of breast cancer, receipt of MRI, higher education level, and increased worry about breast cancer recurrence. In the JAMA Surgery study, the authors assessed patient knowledge about and motivations for CPM. In addition, they evaluated the impact of surgeon recommendations regarding CPM.
Over 2500 women completed the survey. Among those who considered CPM, 38% knew that it would not improve survival, and 44% knew that it did not prevent breast cancer recurrence. In the group of patients considered to be at average risk for the development of another breast cancer (no genetic abnormality or other high risk factors):
- 598 (39%) received a recommendation against CPM and 12 (2%) received it
- 746 (47%) received no recommendation from their physician and 148 (19%) received it
Very few patients who received a recommendation against CPM underwent the procedure. This does not mean that we should go back to the days of physicians telling patients what to do. Rather, the authors noted that “shared decision making requires that physicians participate actively in ensuring that patients’ knowledge is accurate.” This point was reinforced in the invited commentary published with the article. While CPM may turn out to be the right decision for an individual patient, it is important that the decision is made after education and careful consideration of the potential risks, benefits, and limitations of the surgery.