Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer | Breast Cancer | JAMA Surgery | JAMA Network
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Original Investigation
July 2017

Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer

Author Affiliations
  • 1Departments of Internal Medicine and Health Management and Policy, Schools of Medicine and Public Health, University of Michigan, Ann Arbor
  • 2Department of Health Behavior and Education, School of Public Health, University of Michigan, Ann Arbor
  • 3Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor
  • 4Veterans Administration Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan
  • 5Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 6Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
  • 7Memorial Sloan-Kettering Cancer Center, New York, New York
  • 8Department of Radiation Oncology, University of Michigan, Ann Arbor
JAMA Surg. 2017;152(7):658-664. doi:10.1001/jamasurg.2017.0458
Key Points

Question  What is the response of patients to their first surgeon’s recommendations against contralateral prophylactic mastectomy (CPM) with regard to decision satisfaction, receipt of a second opinion, or receipt of surgery from a second surgeon?

Findings  In this population-based survey, one-quarter of patients reported that their surgeon recommended against CPM and one-third noted no substantial discussion about it. Women who received a recommendation against CPM were less satisfied with the surgery decision, but not more likely to seek a second opinion or to receive surgery by a second surgeon.

Meaning  First-surgeon recommendation against CPM does not appear to substantively increase patient dissatisfaction, use of second opinions, or loss of the patient to a second surgeon.

Abstract

Importance  Guidelines assert that contralateral prophylactic mastectomy (CPM) should be discouraged in patients without an elevated risk for a second primary breast cancer. However, little is known about the impact of surgeons discouraging CPM on patient care satisfaction or decisions to seek treatment from another clinician.

Objective  To examine the association between patient report of first-surgeon recommendation against CPM and the extent of discussion about it with 3 outcomes: patient satisfaction with surgery decisions, receipt of a second opinion, and receipt of surgery by a second surgeon.

Design, Setting, and Participants  This population-based survey study was conducted in Georgia and California. We identified 3880 women with stages 0 to II breast cancer treated in 2013-2014 through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery (71% response rate, n = 2578). In this analysis conducted from February to May 2016, we included patients with unilateral breast cancer who considered CPM (n = 1140). Patients were selected between July 2013 and September 2014.

Main Outcomes and Measures  We examined report of surgeon recommendations, level of discussion about CPM, satisfaction with surgical decision making, receipt of second surgical opinion, and surgery from a second surgeon.

Results  The mean (SD) age of patients included in this study was 56 (10.6) years. About one-quarter of patients (26.7%; n = 304) reported that their first surgeon recommended against CPM and 30.1% (n = 343) reported no substantial discussion about CPM. Dissatisfaction with surgery decision was uncommon (7.6%; n = 130), controlling for clinical and demographic characteristics. One-fifth of patients (20.6%; n = 304) had a second opinion about surgical options and 9.8% (n = 158) had surgery performed by a second surgeon. Dissatisfaction was very low (3.9%; n = 42) among patients who reported that their surgeon did not recommend against CPM but discussed it. Dissatisfaction was substantively higher for those whose surgeon recommended against CPM with no substantive discussion (14.5%; n = 37). Women who received a recommendation against CPM were not more likely to seek a second opinion (17.1% among patients with recommendation against CPM vs 15.1% of others; P = .52) nor to receive surgery by a second surgeon (7.9% among patients with recommendation against CPM vs 8.3% of others; P = .88).

Conclusions and Relevance  Most patients are satisfied with surgical decision making. First-surgeon recommendation against CPM does not appear to substantively increase patient dissatisfaction, use of second opinions, or loss of the patient to a second surgeon.

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