Abstract
Since the late 1990s, the use of contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer has been on the rise. Over the past two decades, dozens of studies have been conducted in order to understand this trend, which has puzzled and frustrated physicians who find it at odds with efforts to curb the surgical overtreatment of breast cancer, as well as with evidence-based medicine, which has established that the procedure has little oncologic benefit for most patients. Based on the work of Annemarie Mol and John Law, this paper argues that these efforts to understand increased CPM use are limited by the “epistemology problem” in medicine, or, in other words, the tendency to view healthcare controversies and decision making exclusively through the lenses of objective and subjective forms of knowledge. Drawing on public discourse about rationales for choosing CPM, we argue that this surgical trend cannot adequately be understood in terms of what doctors and patients know about breast cancer risk and how CPM affects that risk. In addition, it must be recognized as the outcome of how specific practices of screening, detection, and treatment do or enact the bodies of patients, producing tensions in their lives that cannot be remedied with better or better communicated information. Recognizing the embodied realities of these enactments and their effects on patient decision making, we maintain, is essential for physicians who want to avoid the paternalism that haunts breast cancer treatment in the US.
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References
Ager, B., P. Butow, J. Jansen, K. Phillips, and D. Porter. 2016. “Contralateral Prophylactic Mastectomy (CPM): A Systematic Review of Patient Reported Factors and Psychological Predictors Influencing Choice and Satisfaction.” The Breast 28:107-120.
Anderson, C., J. Islam, M. Hodgson, S. Sabatino, J. Rodriguez, C. Lee, D. Sandler, and H. Nichols. 2017. “Long-term Satisfaction and Body Image after Contralateral Prophylactic Mastectomy.” Annals of Surgical Oncology 24 (6): 1499-1506.
Angelos, P., I. Bedrosian, D. Euhus, V. Herrmann, S. Katz, and A. Pusic. 2015. “Contralateral Prophylactic Mastectomy: Challenging Considerations for the Surgeon.” Annals of Surgical Oncology 22:3208-3212.
Baptiste, D., E. MacGeorge, M. Venetis, A. Mouton, L. Friley, R. Pastor, K. Hatten, J. Lagoo, S, Clare, and M. Bowling. 2017. “Motivations for Contralateral Prophylactic Mastectomy as a Function of Socioeconomic Status.” BMC Women’s Health 17:1-9.
Bedrosian, Isabelle and Katherine Yao. 2015. “Contralateral Prophylactic Mastectomy: Anxiety, Knowledge, and Shared Decision Making.” Annals of Surgical Oncology 22:3767-3768.
Beesley, H., C. Holcombe, S. L. Brown, P. Salmon. 2013. “Risk, Worry, and Cosmesis in Decision-Making for Contralateral Risk-Reducing Mastectomy: Analysis of 60 Consecutive Cases in a Specialist Breast Unit.” The Breast 22:179-184.
Bellevance, E., J. Peppercorn, S. Kronsberg, R. Greenup, J. Keune, J. Lynch, D. Collyar, L. Magder, J. Tilburt, F. Hlubocky, and K. Yao. 2016. “Surgeon’s Perspectives of Contralateral Prophylactic Mastectomy.” Annals of Surgical Oncology 23:2779-2787.
Benson, J.R. and Z.E. Winters. 2016. “Contralateral Prophylactic Mastectomy.” British Journal of Surgery 103:1249-1250.
Boughey, J., D. Attai, S. Chen, H. Cody, J. Dietz, S. Feldman, C. Greenburg, R. Kass, J. Landercasper, V. Lemaine, F. MacNeill, D. Song, A. Staley, L. Wilke, S. Willey, K. Yao, and J. Margenthaler. 2016a. “Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: Data on CPM Outcomes and Risks.” Annals of Surgical Oncology 23:3100-3105.
_____. 2016b. “Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: Additional Considerations and a Framework for Shared Decision Making.” Annals of Surgical Oncology 23:3106-3111
Covelli, A., N. Baxter, M. Fitch, D. McCready, and F. Wright. 2015. “‘Taking Control of Cancer’: Understanding Women’s Choice for Mastectomy.” Annals of Surgical Oncology 22:383-391.
Greener, J., S. Bass, and S. Lepore. 2018. “Contralateral Prophylactic Mastectomy: A Qualitative Approach to Exploring the Decision Making Process.” Journal of Psychosocial Oncology 36:145-158.
Guth, U., M.E. Myrick, C.T. Viehl, W.P. Weber, A.M. Lardi, and S.M. Schmid. 2011. “Increasing Rates of Contralateral Prophylactic Mastectomy—A Trend Made in the USA?” European Journal of Surgical Oncology 38:296-301.
Han, E., N. Johnson, M. Glissmeyer, T. Wagie, B. Carey, T. DelaMelena, and J. Nelson. 2011. “Increasing Incidence of Bilateral Mastectomies: The Patient Perspective.” The American Journal of Surgery 201:615-618.
Hawley, S., K. Griffith, A. Hamilton, K. Ward, M. Morrow, N. Janz, S. Katz, and R. Jagsi. 2017. “The Association Between Patient Attitudes and Values and the Strength of Consideration for Contralateral Prophylactic Mastectomy in a Population-based Sample of Breast Cancer Patients.” Cancer 123 (23): 4547-4554.
Hawley, S., R. Jagsi, M. Morrow, N. Janz, A. Hamilton, J. Graff, and S. Katz. 2014. “Social and Clinical Determinants of Contralateral Prophylactic Mastectomy.” JAMA Surgery 149:582-589.
Hedge, J., X. Wang, D. Attai, M. DiNome, A. Kusske, A. Hoyt, S. Hurvitz, J. Weidhass, M. Steinberg, and S. McCloskey. 2017. “Assessing the Effect of Lifetime Contralateral Breast Cancer Risk on the Selection of Contralateral Prophylactic Mastectomy for Unilateral Breast Cancer.” Clinical Breast Cancer 18 (2): e205- e218.
Hollingsworth, A.B. 2019. “Redefining the Sensitivity of Screening Mammography: A Review.” The American Journal of Surgery. https://doi.org/10.1016/j.amjsurg.2019.01.039.
Houssami, Nehmat and Nariya Cho. 2018. “Screening Women with a Personal History of Breast Cancer: Overview of the Evidence on Breast Imaging Surveillance.” Ultrasonography 37 (4): 277-287.
Hwang, S., T. Locklear, C. Rushing, G. Samsa, A. Abernethy, T. Hyslop, and D. Atisha. 2016. “Patient-Reported Outcomes After Choice for Contralateral Prophylactic Mastectomy.” Journal of Clinical Oncology 34 (13): 1518-1527.
Kenney, R., M. Reed, A. Subramanian. 2018. “Mastectomy for Risk Reduction or Symmetry in Women Without High Risk Gene Mutation.” International Journal of Surgery 50:60-64.
Knopf Newman, Marcy Jane. 2004. Beyond Slash, Burn, and Poison: Transforming Breast Cancer Stories into Action. New Brunswick: Rutgers University Press.
Kristeva, J., J. Odemark, E. Engebretsen. 2018. “Cultural Crossings of Care: An Appeal to the Medical Humanities.” Medical Humanities 44:55-58.
Kurian, A., D. Lichtensztajn, T. Keegan, D. Nelson, C. Clarke, and S. Gomez. 2014. “Use of and Mortality after Bilateral Mastectomy Compared with Other Surgical Treatments for Breast Cancer in California, 1998-2011.” JAMA 312 (9): 902-914.
Mol, Annemarie. 2008. The Logic of Care: Health and the Problem of Patient Choice. New York: Routledge.
Mol, Annemarie and John Law. 2004. “Embodied Action, Enacted Bodies: The Example of Hypoglycemia.” Body and Society 10:43-62.
Monticciolo, D., M. Newell, L. Moy, B. Niell, B. Monsees, and E. Sickles. 2018. “Breast Cancer Screening in Women at Higher-than-Average Risk: Recommendations from the ACR.” Journal of American College of Radiology 15:408-414.
Nass, Sharyl J. and Larissa Nekhlyudov. 2017. “Commentary on the Consensus Statement of the American Society of Breast Surgeons on Contralateral Prophylactic Mastectomy.” Annals of Surgical Oncology 24:611-613.
Newman, Lisa A. 2014. “Contralateral Prophylactic Mastectomy: Is It a Reasonable Option?” JAMA 312 (9): 895-897.
Orenstein, Peggy. 2014. “The Wrong Approach to Breast Cancer.” New York Times. July 26. https://www.nytimes.com/2014/07/27/opinion/sunday/the-wrong-approach-to-breast-cancer.html.
Plevritis, S., A. Kurian, B. Sigal, B. Daniel, D. Ikeda, F. Stockdale, and A. Garber. 2006. “Cost-Effectiveness of Screening BRCA 1/2 Mutation Carriers with Breast Magnetic Resonance Imaging.” JAMA 295 (20): 2374-2384.
Pope Parker, Tara. 2010. “After Cancer, Removing a Healthy Breast.” New York Times, March 8. https://well.blogs.nytimes.com/2010/03/08/after-cancer-women-remove-healthy- breast/.
Rabin, Roni Caryn. 2017. “More Women Opt to Remove Healthy Breast.” New York Times. March 29. https://www.nytimes.com/2017/03/29/well/live/more-women-with-breast-cancer-opt-to-remove-healthy-breast.html.
_____. 2016. “No Regrets after Double Mastectomy, but Questions Remain.” New York Times. March 21. http://well.blogs.nytimes.com/2016/03/21/no-regrets-after-double-mastectomy-but-questions-remain.html.
Raikhlin, A., B. Curpen, E. Warner, C. Betel, B. Wright, and R. Jong. 2015. “Breast MRI as an Adjunct to Mammography for Breast Cancer Screening In High-Risk Patients: Retrospective Review.” American Journal of Roentgenology 204:889- 897.
Richards, I., S. Tesson, D. Porter, K. Phillips, N. Rankin, T. Musiello, M. Marven, P Butow. 2016. “Predicting Women’s Intentions for Contralateral Prophylactic Mastectomy: An Application of an Extended Theory of Planned Behavior.” European Journal of Oncology Nursing 21:57-65.
Rosenburg, S., M. Tracy, M. Meyer, K. Sepucha, S. Gelber, J. Hirshfield-Bartek, S. Troyan, M. Morrow, L.Schapira, S. Come, E. Winer, and A. Patridge. 2013. “Perceptions, Knowledge, and Satisfaction with Contralateral Prophylactic Mastectomy among Young Women with Breast Cancer.” Annals of Internal Medicine 159:373-381.
Saslow, D., C. Boetes, W. Burke, S. Harms, M. Leach, C. Lehman, E. Morris, E. Pisano, M. Schnall, S. Sener, R. Smith, E. Warner, M. Yaffe, K. Andrews, and C. Russell. 2007. “American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography.” CA: A Cancer Journal for Clinicians 57 (2): 75-89.
Soran, A., A. Polat, R. Johnson, and K. McGuire. 2014. “Increasing Trend of Contralateral Prophylactic Mastectomy: What Are the Factors behind this Phenomenon?” The Surgeon 12:316-322.
Tesson, S., I. Richards, D. Porter, K. Phillips, N. Rankin, T. Musiello, M. Marven, and P. Butow. 2017.“Women’s Preferences for Contralateral Mastectomy: An Investigation Using Protection Motivation Theory.” Patient Education and Counseling 99:814-822.
Tuttle, Todd M., E.B. Habermann, E.H. Grund, T.J. Morris, and B.A. Virnig. 2007. “Increasing Use of Contralateral Prophylactic Mastectomy for Breast Cancer Patients: A Trend Toward More Aggressive Surgical Treatment.” Journal of Clinical Oncology 25:5203-5209.
Tuttle, Todd M. and Erin E. Burke. 2015. “Surgical Decision Making for Breast Cancer: Hitting the Sweet Spot between Paternalism and Consumerism.” Annals of Surgical Oncology 22:351-352.
Yao, K., M. Sisco, and I. Bedrosian. 2016. “Contralateral Prophylactic Mastectomy: Current Perspectives.” International Journal of Women’s Health 8:213-223.
Endnotes
1 A similar argument about the epistemology problem in medicine is made by Kristeva, Odemark, and Engebretsen in their 2018 essay, “Cultural Crossings of Care: An Appeal to the Medical Humanities.”
2 The exceptions here are women with an identified genetic mutation linked to higher breast cancer risk (e.g., a BRCA mutation) or a strong family history. In these cases, CPM can significantly reduce the risk of developing a contralateral breast cancer.
3 Of the 255 comments we read, 120 were in support of CPM, and of those 120, 100 articulated that support in terms of how their bodies and daily lives were affected by breast cancer screening, diagnosis, and treatment practices.
4 Of the 48 CPM articles we read for this project, three were prospective studies of women considering CPM as treatment for breast cancer.
5 See especially Covelli et al.’s 2015 “Taking Control of Cancer: Understanding Women’s Choice for Mastectomy”; Angelos et al.’s 2015, “Contralateral Prophylactic Mastectomy: Challenging Considerations for the Surgeon”; and Tuttle and Burke’s 2015 “Surgical Decision Making for Breast Cancer: Hitting the Sweet Spot between Paternalism and Consumerism.”
6 Take, as an example of such lip service, the claim in Rosenburg et al.’s 2013 study that since many breast cancer patients have misperceptions about risk, “better risk communication strategies” are needed in order to “ensure that treatment decision making is truly evidence-based while remaining patient-centered” (380). “Truly” evidence-based decisions are always going to be decisions against CPM for average-risk women, so for those who want the procedure for reasons other than risk-reduction, the treatment decision-making process will likely never be patient-centered, at least not if it conforms the logic displayed here.
7 Indeed, we agree strongly with the critique of patient choice that Mol puts forward in her 2008 The Logic of Care: Health and the Problem of Patient Choice.
8 This point is demonstrated most compellingly, perhaps, by the small number of CPM studies that try to understand and articulate women’s reasons for choosing CPM outside the realm of subjective thoughts and feelings. In a 2011 study by Han et al., for instance, researchers found that in a group of 237 mastectomy patients, women who chose CPM for treatment of unilateral breast cancer were significantly more satisfied with their decision than women who chose unilateral mastectomy (615-616). They attributed this finding, in part, to better reconstruction with CPM and the reduced need for mammograms, MRIs, or “chronic medications” (e.g., anti-estrogen drugs like tamoxifen) (617). They then concluded that if physicians “examine the optimum goals of therapy from the patient perspective, the trend toward seemingly more invasive surgical therapy for breast cancer becomes understandable” (617). Nass and Nekhlyudov make a similar point in their 2017 commentary on the ASBS consensus statement on CPM. While they agree with the statement that CPM should not be performed routinely in the absence of survival benefit, they acknowledge that this is not the only legitimate reason for women to choose the procedure. For instance, they argue that for young breast cancer patients who have experienced screening difficulties due to dense breast tissue, “the risk-benefit tradeoff for CPM may align well with their personal goals, values, and preferences” (612).
9 Written across seven years and by two authors, these three New York Times articles are very similar in their aims and content. First they explain the trend of increased CPM use, and they pose that trend against the recent effort to curb the surgical overtreatment of breast cancer. They acknowledge some of the factors behind the rise in CPM use (e.g., screening fatigue and desire for symmetry), as well as high rates of patient satisfaction with the procedure. In general, though, they aim to discourage (or at least question) use of CPM, often by quoting physicians who believe that women choose it due to misperceptions about risk and survival benefit.
10 See, for instance, studies by Kurian et al.; Yao, Sisco, and Bedrosian; Tesson et al.; and Kenny, Reed, and Subramanian.
11 MRI is more often recommended for women with a personal history of lobular cancer because this type of breast cancer is harder to detect through mammography.
12 An interval breast cancer is one detected (often through palpation) in the interval between breast cancer screenings.
13 Breast density on mammograms is classified into 4 categories by the Breast Imaging and Reporting Data System (BI-RADS), which was established by the American College of Radiology. Images rated A are almost all fatty tissue; those that receive a B have scattered areas of dense, glandular tissue; those that receive a C are considered heterogeneously dense; and those assigned a D are considered to be extremely dense.
14 A recent review of the literature on the sensitivity of screening mammography suggests that the test has about an 80% sensitivity rate overall and about a 50% sensitivity rate for women with dense breasts. As the review notes, though, about half of the population of women undergoing screening mammography have dense breasts, so to say the test has 80% sensitivity overall is misleading (Hollingsworth 2019, n.p.). As for breast MRI, it has very high sensitivity rates, but relatively lower specificity rates. A 2006 JAMA study, for instance, found that the likelihood of additional testing after an initial MRI was 32%. That rate decreased for subsequent MRIs but only to 20% (Plevritis et al. 2006, 2377). When the American Cancer Society published their updated screening guidelines for high-risk women in 2007, they noted that in all studies to date, MRI had significantly lower specificity than mammography, resulting in high callback rates for the test, with some community practices reporting callback rates as high as 50% (Saslow et al. 2007, 81-82). And more recently, a 2015 study found that the lower specificity of MRI leads to more callbacks than mammography, as well as more breast biopsies (Raikhlin et al. 2015, 889).
15 In addition to categorizing levels of breast density, the American College of Radiology uses a BI-RADS system to rate the likelihood that a lesion identified through breast cancer screening is malignant. The threshold for conducting a biopsy on an identified lesion is very low. If a radiologist believes there is anywhere from a 3% to 95% chance that it is malignant, he or she assigns it a BI-RADS 4 rating, which means that it is “suspicious for malignancy” and a biopsy should be performed. If he or she believes there is more than a 95% chance the lesion is malignant, then it gets a BI-RADS 5 rating, which means “highly suspicious for malignancy” and, again, a biopsy is recommended. Designed to prevent false negatives (or, in other words, missed cancers), this system inadvertently leads to many false positives, or unnecessary biopsies.
16 Some researchers are headed in this direction, though. In their 2018 review article, “Mastectomy for Risk-Reduction or Symmetry in Women without a High-Risk Gene Mutation,” Kenny, Reed, and Subramanian acknowledge how difficult it can be to achieve symmetry between one natural breast and one reconstructed breast. Thus they refer to CPM as a “symmetrization procedure” (63).
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Pender, K., Covington, B. How Contralateral Prophylactic Mastectomy Does the Body, or Why Epistemology Alone Cannot Explain this Controversial Breast Cancer Treatment. J Med Humanit 43, 141–158 (2022). https://doi.org/10.1007/s10912-020-09614-w
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DOI: https://doi.org/10.1007/s10912-020-09614-w