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Original Investigation
December 21, 2016

Contralateral Prophylactic Mastectomy Decisions in a Population-Based Sample of Patients With Early-Stage Breast Cancer

Author Affiliations
  • 1Department of Radiation Oncology, University of Michigan, Ann Arbor
  • 2Department of Internal Medicine, University of Michigan, Ann Arbor
  • 3Department of Health Management and Policy, University of Michigan, Ann Arbor
  • 4Ann Arbor Veterans Affairs Health Care System, Ann Arbor
  • 5University of Michigan Center for Cancer Biostatistics, Ann Arbor
  • 6Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
  • 7Stanford University School of Medicine, Stanford, California
  • 8Emory University, Atlanta, Georgia
  • 9Keck School of Medicine, University of Southern California, Los Angeles
  • 10Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Surg. Published online December 21, 2016. doi:10.1001/jamasurg.2016.4749
Key Points

Questions  How often do patients with breast cancer perceive recommendations from surgeons against contralateral prophylactic mastectomy, and how do surgeon recommendations affect the use of this aggressive approach?

Findings  In this survey of a diverse, population-based sample of patients with breast cancer without high genetic risk or mutation, approximately one-third reported a surgeon recommendation against contralateral prophylactic mastectomy, and few of these women received it, but more women who received no recommendation for or against contralateral prophylactic mastectomy from a surgeon selected it.

Meaning  Contralateral prophylactic mastectomy use is substantial among patients without a high risk of contralateral cancer development but is low when patients report that their surgeon recommended against the operation, suggesting that more effective physician-patient communication about contralateral prophylactic mastectomy could reduce potential overtreatment.

Abstract

Importance  Contralateral prophylactic mastectomy (CPM) use is increasing among women with unilateral breast cancer, but little is known about treatment decision making or physician interactions in diverse patient populations.

Objective  To evaluate patient motivations, knowledge, and decisions, as well as the impact of surgeon recommendations, in a large, diverse sample of patients who underwent recent treatment for breast cancer.

Design, Setting, and Participants  A survey was sent to 3631 women with newly diagnosed, unilateral stage 0, I, or II breast cancer between July 2013 and September 2014. Women were identified through the population-based Surveillance Epidemiology and End Results registries of Los Angeles County and Georgia. Data on surgical decisions, motivations for those decisions, and knowledge were included in the analysis. Logistic and multinomial logistic regression of the data were conducted to identify factors associated with (1) CPM vs all other treatments combined, (2) CPM vs unilateral mastectomy (UM), and (3) CPM vs breast-conserving surgery (BCS). Associations between CPM receipt and surgeon recommendations were also evaluated. All statistical models and summary estimates were weighted to be representative of the target population.

Main Outcomes and Measures  Receipt of CPM was the primary dependent variable for analysis and was measured by a woman’s self-report of her treatment.

Results  Of the 3631 women selected to receive the survey, 2578 (71.0%) responded and 2402 of these respondents who did not have bilateral disease and for whom surgery type was known constituted the final analytic sample. The mean (SD) age was 61.8 (12) years at the time of the survey. Overall, 1301 (43.9%) patients considered CPM (601 [24.8%] considered it very strongly or strongly); only 395 (38.1%) of them knew that CPM does not improve survival for all women with breast cancer. Ultimately, 1466 women (61.6%) received BCS, 508 (21.2%) underwent UM, and 428 (17.3%) received CPM. On multivariable analysis, factors associated with CPM included younger age (per 5-year increase: odds ratio [OR], 0.71; 95% CI, 0.65-0.77), white race (black vs white: OR, 0.50; 95% CI, 0.34-0.74), higher educational level (OR, 1.69; 95% CI, 1.20-2.40), family history (OR, 1.63; 95% CI, 1.22-2.17), and private insurance (Medicaid vs private insurance: OR, 0.47; 95% CI, 0.28-0.79). Among 1569 patients (65.5%) without high genetic risk or an identified mutation, 598 (39.3%) reported a surgeon recommendation against CPM, of whom only 12 (1.9%) underwent CPM, but among the 746 (46.8%) of these women who received no recommendation for or against CPM from a surgeon, 148 (19.0%) underwent CPM.

Conclusions and Relevance  Many patients consider CPM, but knowledge about the procedure is low and discussions with surgeons appear to be incomplete. Contralateral prophylactic mastectomy use is substantial among patients without clinical indications but is low when patients report that their surgeon recommended against it. More effective physician-patient communication about CPM is needed to reduce potential overtreatment.

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