Social and Clinical Determinants of Contralateral Prophylactic Mastectomy

Abstract

Importance The growing rate of contralateral prophylactic mastectomy (CPM) among women diagnosed with breast cancer has raised concerns about potential for overtreatment. Yet, there are few large survey studies of factors that affect women’s decisions for this surgical treatment option. Objective To determine factors associated with use of CPM in a population-based sample of breast cancer patients. Design, Setting and Participants A longitudinal survey of 2290 women newly diagnosed with breast cancer and reported to the Detroit and Los Angeles SEER registries from 6/05-2/07 and again 4 years later (6/09-2/10) merged with SEER registry data (n=1536). Multinomial logistic regression was used to evaluate factors associated with type of surgery. Primary independent variables included clinical indications for CPM (genetic mutation and/or strong family history), diagnostic MRI, and patient extent of worry about recurrence at the time of treatment decision making. Main outcome measure Type of surgery received from patient self-report, categorized as CPM, unilateral mastectomy (UM) or breast conservation surgery (BCS). Results Of the 1443 women in the analytic sample, 19% strongly considered CPM and 7.6% received it. Of those who strongly considered CPM, 45.8% ultimately received UM and 22.8% received BCS. The majority (69%) of patients who received CPM had no major genetic or familial risk factors for contralateral disease. Multivariate regression showed that receipt of CPM (vs. either UM or BCS) was significantly (P<0.01) associated with genetic testing (positive or negative), a strong family history of breast/ovarian cancer, receipt of MRI, higher education, and greater worry about recurrence. Conclusions Many women considered CPM and a substantial number received it, although few had clinically significant risk of contralateral breast cancer. Receipt of MRI at diagnosis contributed to receipt of CPM. Worry about recurrence appeared to drive decisions for CPM though the procedure has not been shown to reduce recurrence risk. More research is needed about the underlying factors driving utilization of CPM.

Contralateral prophylactic mastectomy (CPM): A systematic review of patient reported factors and psychological predictors influencing choice and satisfaction

“…Psychological factors considered included perception of risk [28,30], distress/anxiety [28,30], neuroticism [30], breast cancer knowledge [30], causal beliefs about cancer [31] and worry about BC recurrence [29]. Three studies were cross-sectional [28,30,31]: one study [30] surveyed women within 6 weeks of a BC diagnosis whilst two of the studies [28,31] surveyed women after surgery.…”

“…Three studies were cross-sectional [28,30,31]: one study [30] surveyed women within 6 weeks of a BC diagnosis whilst two of the studies [28,31] surveyed women after surgery. Only one study [29] employed a longitudinal approach. Quality ratings ranged from 55% [31] to 100% [29] with two studies [29,30] considered high standard and two studies [28,31] of an adequate standard.…”

“…Only one study [29] employed a longitudinal approach. Quality ratings ranged from 55% [31] to 100% [29] with two studies [29,30] considered high standard and two studies [28,31] of an adequate standard.…”

“…Two studies [28,29] compared women who had CPM to women who did not have CPM. Specifically, one study [28] compared perceptions of risk, psychological distress and estimates of an average woman's BC risk between those who had breast conserving surgery/unilateral mastectomy and women who had bilateral mastectomy/CPM.…”

“…No differences were found in these variables between surgery types. However a longitudinal study [29] which included women who had 'strongly considered' CPM and compared women who eventually did and did not have CPM over a period of approximately 3 years, found that women who had CPM were more often 'very worried' about recurrence compared to women who did not have CPM.…”