One in six women with early-stage unilateral breast cancer undergoes double mastectomy even when it is unlikely to provide a survival benefit, according to a recent Jama Surgery study.
For breast cancer patients who have a genetic mutation that makes a second cancer significantly more likely, removing both breasts may be physician-recommended. Data from the study and from previous research, however, indicate women at low risk are still choosing this aggressive option over less-invasive breast conservation — often for peace of mind.
A Painful Calculus
“High cancer worry” and availability of reconstructive surgery are associated with greater likelihood that a woman will choose contralateral prophylactic mastectomy (CPM), according to a 2016 article in the International Journal of Women’s Health. Findings from the JAMA Surgery article provide additional evidence that a dispassionate assessment of the data does not always inform that choice: Only about 38 percent of those who considered CPM realized it does not always improve survival for women who have breast cancer.
“It’s intuitive to think ... more aggressive surgery should give you a better chance of surviving cancer to be there for the people who need you,” says the lead researcher for the JAMA Surgery study, Reshma Jagsi, MD, DPhil, Professor, Department Chair, Department of Radiation Oncology, University of Michigan. “It’s somewhat counterintuitive to understand why it is that removing the unaffected breast is unlikely to actually allow you to be there for the people you want to be there for any more than receiving breast conservation.”
During this stressful time, patients may not be able to fully process the data and the risks regarding more aggressive surgical options, and fear may lead them to overestimate their actual risk of developing cancer in the unaffected breast, says Oluwadamilola “Lola” Fayanju, MD, Assistant Professor of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery, Breast Surgery, at Duke Surgery, who wrote an editorial accompanying the JAMA Surgery article.
Physicians can play a vital role, however, in guiding the discussion. Study results show that when patients perceived a clear physician recommendation against CPM, the rate of procedure dipped as low as 2.1 percent. When they sensed a clear physician recommendation for it, the rate rose to almost 60 percent.
“Using that recommendation in a strong way — ‘I recommend you do not have this procedure’ — is a powerful tool that could be brought into the conversation if the surgeon believed the patient was, perhaps, making decisions with poor information or really valued something they weren’t going to obtain with said procedure,” says Sarah T. Hawley, PhD, MPH, Professor, Division of General Medicine, University of Michigan, and a researcher for the JAMA Surgery study.
Before offering a recommendation for or against CPM, providers should listen carefully to patients’ values, needs and preferences, researchers say. After educating the patient about the risks and benefits of CPM and other surgical options, providers can guide patients through the decision-making process to find the optimal treatment plan, according to Dr. Jagsi.