Abstract
Background
Contralateral prophylactic mastectomy (CPM) is commonly performed for the treatment of breast cancer, despite its limited oncologic benefit. Little is known about surgeons’ perceptions of performing CPM. We hypothesized that a proportion of surgeons would report discomfort with performing CPM, particularly when there is discordance between patients’ perceived benefit from CPM and the expected oncologic benefit.
Methods
A survey was sent to members of the American Society of Breast Surgeons seeking self-reports of surgeons’ practice patterns, perceptions, and comfort levels with CPM.
Results
Of the 2436 members surveyed, 601 responded (response rate = 24.7 %). The median age of respondents was 52 years, and 59 % of responders were women. The majority (58 %) reported that 80 % of their practice was devoted to the treatment of breast disease. Fifty-seven percent (n = 326) of respondents reported discomfort with performing CPM at some point in their practice. While most surgeons (95 %) were comfortable with CPM on a patient with a deleterious BRCA mutation, only 34 % were comfortable performing CPM on an average-risk patient. The most common reasons reported for surgeon discomfort with CPM were a concern for overtreatment, an unfavorable risk/benefit ratio, and inadequate patient understanding of the anticipated risks and benefits of CPM.
Conclusions
Despite the increasing use of CPM for the treatment of breast cancer, many surgeons report discomfort with CPM. Concerns with performing CPM predominantly focus on ambiguities surrounding the oncologic benefit and relative risk of this procedure. Further research is needed to define optimal shared decision-making practices in this area.
Similar content being viewed by others
References
Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203–9.
Tuttle TM, Jarosek S, Habermann EB, et al. Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ. J Clin Oncol. 2009;27(9):1362–7.
Yao K, Stewart AK, Winchester DJ, Winchester DP. Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998–2007. Ann Surg Oncol. 2010;17(10):2554–62.
King TA, Sakr R, Patil S, et al. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol. 2011;29(16):2158–64.
Yi M, Hunt KK, Arun BK, et al. Factors affecting the decision of breast cancer patients to undergo contralateral prophylactic mastectomy. Cancer Prev Res (Phila). 2010;3(8):1026–34.
Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, Gomez SL. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998–2011. JAMA. 2014;312(9):902–14.
Covelli AM, Baxter NN, Fitch MI, McCready DR, Wright FC. ‘Taking control of cancer’: understanding women’s choice for mastectomy. Ann Surg Oncol. 2015;22(2):383–91.
Rosenberg SM, Tracy MS, Meyer ME, et al. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey. Ann Intern Med. 2013;159(6):373–81.
Temple WJ, Russell ML, Parsons LL, et al. Conservation surgery for breast cancer as the preferred choice: a prospective analysis. J Clin Oncol. 2006;24(21):3367–73.
Molenaar S, Oort F, Sprangers M, et al. Predictors of patients’ choices for breast-conserving therapy or mastectomy: a prospective study. Br J Cancer. 2004;90(11):2123–30.
Nold RJ, Beamer RL, Helmer SD, McBoyle MF. Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified radical mastectomy. Am J Surg. 2000;180(6):413–8.
Parker PA, Peterson SK, Bedrosian I, et al. Prospective study of surgical decision-making processes for contralateral prophylactic mastectomy in women with breast cancer. Ann Surg. 2015;22.
Musiello T, Bornhammar E, Saunders C. Breast surgeons’ perceptions and attitudes towards contralateral prophylactic mastectomy. ANZ J Surg. 2013;83(7–8):527–32.
Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect. 2007;10(3):248–58.
Keating NL, Beth Landrum M, Arora NK, et al. Cancer patients’ roles in treatment decisions: do characteristics of the decision influence roles? J Clin Oncol. 2010;28(28):4364–70.
Abbott A, Rueth N, Pappas-Varco S, Kuntz K, Kerr E, Tuttle T. Perceptions of contralateral breast cancer: an overestimation of risk. Ann Surg Oncol. 2011;18(11):3129–36.
Han E, Johnson N, Glissmeyer M, et al. Increasing incidence of bilateral mastectomies: the patient perspective. Am J Surg. 2011;201(5):615–8.
Peppercorn J, Burstein H, Miller FG, Winer E, Joffe S. Self-reported practices and attitudes of US oncologists regarding off-protocol therapy. J Clin Oncol. 2008;26(36):5994–6000.
Daugherty CK, Hlubocky FJ. What are terminally ill cancer patients told about their expected deaths? A study of cancer physicians’ self-reports of prognosis disclosure. J Clin Oncol. 2008;26(36):5988–93.
Agarwal S, Kidwell KM, Kraft CT, et al. Defining the relationship between patient decisions to undergo breast reconstruction and contralateral prophylactic mastectomy. Plast Reconstr Surg. 2015;135(3):661–70.
Mavaddat N, Peock S, Frost D, et al. Cancer risks for BRCA1 and BRCA2 mutation carriers: results from prospective analysis of EMBRACE. J Natl Cancer Inst. 2013;105(11):812–22.
Meijers-Heijboer H, van Geel B, van Putten WL, et al. Breast cancer after prophylactic bilateral mastectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med. 2001;345(3):159–64.
Metcalfe K, Lynch HT, Ghadirian P, et al. Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. J Clin Oncol. 2004;22(12):2328–35.
Kruper L, Kauffmann RM, Smith DD, Nelson RA. Survival analysis of contralateral prophylactic mastectomy: a question of selection bias. Ann Surg Oncol. 2014;21(11):3448–56.
Portschy PR, Kuntz KM, Tuttle TM. Survival outcomes after contralateral prophylactic mastectomy: a decision analysis. J Natl Cancer Inst. 2014;106(8):dju160.
Bedrosian I, Hu CY, Chang GJ. Population-based study of contralateral prophylactic mastectomy and survival outcomes of breast cancer patients. J Natl Cancer Inst. 2010;102(6):401–9.
Nichols HB, Berrington de Gonzalez A, Lacey JV, Jr., Rosenberg PS, Anderson WF. Declining incidence of contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol. 2011;29(12):1564–9.
Gao X, Fisher SG, Emami B. Risk of second primary cancer in the contralateral breast in women treated for early-stage breast cancer: a population-based study. Int J Radiat Oncol Biol Phys. 2003;56(4):1038–45.
Heemskerk-Gerritsen BA, Rookus MA, Aalfs CM, et al. Improved overall survival after contralateral risk-reducing mastectomy in BRCA1/2 mutation carriers with a history of unilateral breast cancer: a prospective analysis. Int J Cancer. 2015;136(3):668–77.
van der Kolk DM, de Bock GH, Leegte BK, et al. Penetrance of breast cancer, ovarian cancer and contralateral breast cancer in BRCA1 and BRCA2 families: high cancer incidence at older age. Breast Cancer Res Treat. 2010;124(3):643–51.
Brewster AM, Bedrosian I, Parker PA, et al. Association between contralateral prophylactic mastectomy and breast cancer outcomes by hormone receptor status. Cancer. 2012;118(22):5637–43.
Boughey JC, Hoskin TL, Degnim AC, et al. Contralateral prophylactic mastectomy is associated with a survival advantage in high-risk women with a personal history of breast cancer. Ann Surg Oncol. 2010;17(10):2702–9.
Lee JS, Grant CS, Donohue JH, Crotty TB, Harmsen WS, Ilstrup DM. Arguments against routine contralateral mastectomy or undirected biopsy for invasive lobular breast cancer. Surgery. 1995;118(4):640–7; discussion 647-8.
Peralta EA, Ellenhorn JD, Wagman LD, Dagis A, Andersen JS, Chu DZ. Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer. Am J Surg. 2000;180(6):439–45.
Herrinton LJ, Barlow WE, Yu O, et al. Efficacy of prophylactic mastectomy in women with unilateral breast cancer: a cancer research network project. J Clin Oncol. 2005;23(19):4275–86.
Boughey JC, Hoskin TL, Hartmann LC, et al. Impact of reconstruction and reoperation on long-term patient-reported satisfaction after contralateral prophylactic mastectomy. Ann Surg Oncol. 2015;22(2):401–8.
Yao K, Winchester DJ, Czechura T, Huo D. Contralateral prophylactic mastectomy and survival: report from the National Cancer Data Base, 1998-2002. Breast Cancer Res Treat. 2013;142(3):465–76.
Jatoi I, Parsons HM. Contralateral prophylactic mastectomy and its association with reduced mortality: evidence for selection bias. Breast Cancer Res Treat. 2014;148(2):389–96.
Soran A, Ibrahim A, Kanbour M, et al. Decision making and factors influencing long-term satisfaction with prophylactic mastectomy in women with breast cancer. Am J Clin Oncol. 2015;38(2):179–83.
Miller ME, Czechura T, Martz B, et al. Operative risks associated with contralateral prophylactic mastectomy: a single institution experience. Ann Surg Oncol. 2013;20(13):4113–20.
Osman F, Saleh F, Jackson TD, Corrigan MA, Cil T. Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database. Ann Surg Oncol. 2013;20(10):3212–7.
Sharpe SM, Liederbach E, Czechura T, Pesce C, Winchester DJ, Yao K. Impact of bilateral versus unilateral mastectomy on short term outcomes and adjuvant therapy, 2003–2010: a report from the National Cancer Data Base. Ann Surg Oncol. 2014;21(9):2920–7.
de Melo Gagliato D, Gonzalez-Angulo AM, Lei X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32(8):735–44.
Yao K, Belkora J, Sisco M, et al. Survey of the deficits in surgeons’ knowledge of contralateral prophylactic mastectomy. JAMA Surg. (2015), 25:1–3.
Beitsch PD, Whitworth PW. Can breast surgeons provide breast cancer genetic testing? An American Society of Breast Surgeons survey. Ann Surg Oncol. 2014;21(13):4104–8.
DeSnyder SM, Hunt KK, Smith BD, Moran MS, Klimberg S, Lucci A. Assessment of practice patterns following publication of the SSO-ASTRO consensus guideline on margins for breast-conserving therapy in stage I and II invasive breast cancer. Ann Surg Oncol. 2015;22(10):3250–6.
Schubart JR, Dominici LS, Farnan M, et al. Shared decision making in breast cancer: national practice patterns of surgeons. Ann Surg Oncol. 2013;20(10):3323–9.
Disclosures
Jeffery Peppercorn: Spouse is employed by GlaxcoSmithKline Inc. Deborah Collyar: Honoraria, travel and accommodations from Merck. Fay Hlubocky: Speaker’s Bureau for Lilly Oncology.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Bellavance, E., Peppercorn, J., Kronsberg, S. et al. Surgeons’ Perspectives of Contralateral Prophylactic Mastectomy. Ann Surg Oncol 23, 2779–2787 (2016). https://doi.org/10.1245/s10434-016-5253-9
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-016-5253-9