Prospective Study of Surgical Decision-making Processes for Contralateral Prophylactic Mastectomy in Women With Breast Cancer

Abstract

Structured Abstract Objective We prospectively examined the psychosocial predictors and the decision-making process regarding contralateral prophylactic mastectomy (CPM) among women with sporadic breast cancer. Summary Background Data Increasing numbers of women with breast cancer are seeking CPM. Data are limited about the surgical decision-making process and the psychosocial factors that influence interest in CPM. Methods Women with early stage unilateral breast cancer (n=117) were recruited before their first surgical visit at MD Anderson and completed questionnaires assessing knowledge of and interest in CPM and associated psychosocial factors. After the appointment, women and their surgeons completed questions about the extent that various surgical options (including CPM) were discussed; also, the women rated their perceived likelihood of having CPM and the surgeons rated the appropriateness of CPM. Results Before their first visit, 50% of women were moderately to extremely interested in CPM and 12 (10%) of women had CPM at the time of their primary breast cancer surgery. Less knowledge about breast cancer (P=0.02) and greater cancer worry (P=0.03) predicted interest in CPM. Greater cancer worry predicted who had CPM (P=0.02). Interest in CPM before surgical visit and the likelihood of having CPM after the visit differed (P =<0.001). Surgeons’ rating of the appropriateness of CPM and the patient’s reported likelihood of having CPM were not significantly different (P=0.49). Conclusions Interest in CPM is common among women with sporadic breast cancer. The informational and emotional aspects of CPM may affect the decision to have CPM and should be addressed when discussing surgical options.

Tradeoffs Associated With Contralateral Prophylactic Mastectomy in Women Choosing Breast Reconstruction

“…Multiple investigators have cited anxiety as an important factor in the decision making process for women to choose CPM, 21, 22, 23 but few have directly measured preoperative anxiety levels using validated PRO instruments. 24, 25 A prospective questionnaire based study on the surgical decision-making process for CPM showed that patients with less knowledge about breast cancer and greater worry were more interested in CPM. 25 Greater cancer worry ultimately was a significant predictor for patients who went on to have CPM.…”

Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: Additional Considerations and a Framework for Shared Decision Making

“…In a recent study, more than 50 % of women with sporadic breast cancer were initially interested in CPM, but only 10 % underwent CPM 39. Although patients claim CPM discussion rates of 45–80 % with their doctor, only half of patients relay that their doctors outlined reasons not to have CPM 38,39. Given that approximately one-third of patients in one study experienced worse than expected results, this discussion may serve as an educational opportunity for providers to optimize informed consent 20.…”

“…Surgeons should encourage patients to actively participate in the decision-making process and try to elicit patient’s treatment preferences. Since many patients consider CPM somewhere in their decision-making process, surgeons should make a recommendation based on their expert opinion after weighing the evidence and reviewing the risks and benefits of CPM with the patient 39. The surgeon is responsible for informing the patient about CPM’s impact on outcomes, both physical and psychological, engaging the patient in the decision-making process, and ensuring that patients are making treatment decisions that are concordant with their personal values and goals.…”

Contralateral Prophylactic Mastectomy: Anxiety, Knowledge and Shared Decision Making

“…Indeed, in almost all studies on the topic, fear of and desire to avoid recurrence and ''peace of mind'' are oft-cited reasons by women who choose to undergo CPM. 9,10 These emotional factors may conflate not only the perceived risk of second malignancy but whatever survival benefit CPM provides. These factors may contribute to the internal dissonance in women who may objectively understand the data around CPM but subjectively feel compelled nonetheless to pursue a CPM.…”