Commentary on the Consensus Statement of the American Society of Breast Surgeons on Contralateral Prophylactic Mastectomy

Abstract

The increasing rate of contralateral prophylactic mastectomy (CPM) led the American Society of Breast Surgeons (ASBrS) to issue an evidence-based consensus statement on CPM, as well as a discussion guide that health care providers can use to facilitate shared decision making with patients considering CPM for unilateral breast cancer. This article suggests several ways to improve the discussion guide by eliciting patient values and preferences and by providing more current, detailed, and balanced information about the potential risks and benefits of CPM.We commend the American Society of Breast Surgeons (ASBrS) for addressing the complex issue of contralateral prophylactic mastectomy (CPM) with a thorough review of the data and a well-balanced consensus statement. 1 We are concerned, however, that the discussion guide for shared decision making does not achieve the authors' stated goal of considering ''the patient's preferences and values and an informed discussion of the risks and benefits of CPM.'' 2 None of the talking points guide the provider in eliciting a patient's preferences and values. Also, only one talking point includes a potential benefit of CPM (that women who undergo CPM will not need mammograms or routine breast imaging for cancer screening after surgery), whereas the remaining talking points focus on the harms and limitations. Overall, the selection and framing of many of the discussion points are intended to discourage CPM (a stated goal) rather than provide a neutral overview of the individualized potential risks and benefits of CPM.Shared decision making has been defined as a collaborative process that allows patients and their health care providers to make well-informed decisions together with the goal of achieving outcomes that matter most to the patient.3 Well-designed patient decision aids have been shown to enhance patient knowledge and improve the quality of these decisions, including decisions about breast cancer surgery.4,5 A systematic Cochrane Review found that compared with standard care, patient decision aids can enhance patient understanding, including substantial improvement of perceived personal risk, and lead to a better match between values and choices, with no or minimal effect on anxiety, depression, regret, consultation length, or health-related quality of life. 6The International Patient Decision Aids Standards (IPDAS) Collaboration has established a framework for improving the content, development, implementation, and evaluation of patient decision aids, including checklists, tools for evaluation, and minimal standards. 7,8 Their framework calls for a systematic development process using up-to-date evidence, balancing presentation of information and options, clarifying values and preferences, and measuring effectiveness.We encourage the ASBrS to facilitate shared decision making by engaging a multidisciplinary group of experts and applying the IPDAS framework to strengthen and evaluate their discussion guide. We also suggest specific ways to improve several poin...

Cracking open the eristic rhetoric of contralateral prophylactic mastectomy research or why surgeons should not be so certain about this controversial breast cancer treatment

“…Some studies identified women’s reasons for choosing CPM and then, based on those reasons, argued that the procedure is a reasonable treatment choice for average-risk women. See, for example, Han et al (2011) and . Importantly, though, these instances truly are exceptions, and, further, they appear to have had little impact insofar as their arguments are not generally picked up and cited in other studies.…”