Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer

Abstract

Background: For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breastconserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. Methods: Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. Results: Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women !70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/ estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models.Conclusions: Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM.Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.

Neighborhood socioeconomic status and low‐value breast cancer care

“…42,43 Rates subsequently decreased from 2013 to 2016, indicating a downturn in CPM utilization in more recent years. 44 Our results similarly show that CPM increased until 2013 when rates began to decline, coinciding with the publication of the Choosing Wisely guidelines and the American Society of Breast Surgeons CPM guidelines. 7,8,45 Despite the decline, however, only 42% of patients who have undergone CPM between 2013 and 2018 had justifiable medical reasons such as BRCA + or lobular histology.…”

Peace of Mind: A Role in Unnecessary Care?

“…21 Nevertheless, rates of CPM continue to increase in the average-risk population. 29 It is important to acknowledge that despite treatment risks, there can be benefits to choosing more extensive treatment over less extensive treatment. Patients may choose more extensive treatment for reasons other than peace of mind.…”

Improved Survival after Breast-Conserving Therapy Compared with Mastectomy in Stage I-IIA Breast Cancer

“…Despite the many benefits observed with BCT, the rates of unilateral or bilateral mastectomies for patients with unilateral breast cancer, who are candidates for BCT, are on the rise [29,64]. Perceived risks such as a fear of developing a second breast cancer, a historical belief that mastectomy is a safer option, possible avoidance of long-term breast cancer surveillance imaging, and the inconvenience of daily radiotherapy treatments may all have contributed to increasing mastectomy rates, which is of concern [53,[65][66][67].…”

“…Nevertheless, breast-conserving surgery rates, as commonly reported, have reached a plateau in the last decade. In 2010-2011, breast-conserving surgery rates for the general population with unilateral EBC were 64.5-69% in the US [27][28][29], 73.3% in Europe [30], and 36.5-49.4% for patients younger than 50 years [28,31]. However, in some countries, the overall rate of breast-conserving surgery is lower than 50% [32,33].…”