Contralateral Prophylactic Mastectomy: Anxiety, Knowledge and Shared Decision Making

Abstract

With the steady increase of contralateral prophylactic mastectomy (CPM) now well documented, attention increasingly has been directed at understanding the potential reasons driving utilization of this treatment approach. A key area is examining the perspective of patients who are making this choice and how this perspective may differ from those choosing more limited surgery. In this issue of the Annals of Surgical Oncology, Rosenberg et al. detail the decisionmaking process of young women who have opted for bilateral mastectomy. Using a large registry of young women, they explore psychological, emotional, and decision-making aspects of the choice for surgical management of breast cancer. In this cohort of patients younger than age 40 years, most of whom are not known to be BRCA 1/2 mutation carriers, they report that nearly half of the study population underwent CPM. They confirm prior associations between anxiety and fear and use of CPM and provide new insights about how surgical decisions vary depending on who is driving the decision: the physician or the patient. Significantly, nearly two-thirds of women who stated that the choice of surgical therapy was self-driven chose CPM. In stark contrast, women who reported that the decision was made by their doctor had very low rates (6 %) of CPM. In multivariate analysis, patient-driven decision was associated with threefold greater likelihood of CPM compared with those who reported shared decision making. While physician influences on use of CPM has previously been suggested, Rosenberg et al. provide more direct evidence that physician interaction and engagement on this topic may represent one opportunity to reverse the increasing utilization of CPM.

Considerations for the Treatment of Young Patients with Breast Cancer

“…Consensus guidelines stress that providers clarify the important differences between risk reduction and oncologic benefit during the surgical decision‐making process so that therapeutic decisions reflect a balance between the risk of recurrence of the diagnosed breast cancer and the potential benefit of preventing a second primary cancer or recurrence . If a woman does elect for unilateral or bilateral mastectomy, consensus guidelines suggest that immediate reconstruction should be offered .…”

Effects of High Anxiety Scores on Surgical and Overall Treatment Plan in Patients with Breast Cancer Treated with Neoadjuvant Therapy

“…However, patients treated neoadjuvantly benefit from a longer period to reach a decision and consider a wider breadth of options. The impact of high anxiety on surgical decision‐making has been demonstrated in various cancer settings . For women with breast cancer, a desire to reduce the risk of contralateral breast cancer and improve survival is most often identified as a driving factor in their decision to have a PCM .…”

“…For women with breast cancer, a desire to reduce the risk of contralateral breast cancer and improve survival is most often identified as a driving factor in their decision to have a PCM . However, knowledge gaps exist , and patients are increasingly vulnerable to misinformation given widely available non–peer‐reviewed online content and social media. Indeed, many women report that their choices for locoregional management of breast cancer are reflective of their desire to reduce the risk of systemic recurrence and breast cancer mortality .…”

Variables associated with length of stay in patients undergoing mastectomy and delayed‐immediate breast reconstruction with tissue expander

“…Aggressive surgical treatments continue despite evidence that the incidence of contralateral breast cancer incidence is decreasing and that breast‐conserving therapy offers similar survival benefits . Data suggest that the shift toward mastectomy is related to patient anxiety, fear of recurrence and diagnosis of gene mutation, and the increasing availability of breast reconstruction …”

“…[2][3][4] Data suggest that the shift toward mastectomy is related to patient anxiety, fear of recurrence and diagnosis of gene mutation, and the increasing availability of breast reconstruction. [3][4][5][6][7][8] A common approach to breast reconstruction is delayed-immediate breast reconstruction (the placement of a tissue expander at the time of mastectomy). While there are valuable social and emotional benefits for patients, combining mastectomy and reconstruction is more invasive, adds operative time and has a higher risk of postoperative complications.…”