Patient-Physician Communication Can Influence Decisions on CPM, Avoid Overtreatment

Contralateral prophylactic mastectomy (CPM)—removal of the healthy breast along with the cancerous breast—has been rising over the years, even among women who are at a low risk of developing contralateral cancer. However, a new study has found that women chose not to go ahead with the procedure if their surgeon recommended against it.

“That 1 in 6 breast cancer patients chose bilateral mastectomy is really striking. We knew it was increasing, but I don’t think many of us realized just how frequent this is,” study author Reshma Jagsi, MD, DPhil, professor and deputy chair of radiation oncology at the University of Michigan, said in a statement.

For their study, published in JAMA Surgery, researchers sent a survey to 3631 women, identified via the Surveillance Epidemiology and End Results registries, who were newly diagnosed with unilateral stage 0, I, or II breast cancer between July 2013 and September 2014. The survey included questions on surgical decisions, motivations for those decisions, and knowledge. Subsequent analysis of the data identified factors that were associated with:

• CPM versus other treatments
• CPM versus unilateral mastectomy (UM)
• CPM versus breast-conserving surgery (BCS)

Only 71% (2578) of women who received the survey responded—of these, 2402 who did not have bilateral disease, and for whom the surgery type was known, were included in the final analysis. Nearly 44% (1301) of these patients considered CPM, 38% (395) of whom know that CPM does not improve survival for all women with breast cancer. It is noteworthy that more than 60% of women had a poor understanding of the benefits rendered by this procedure.

The analysis showed that age, white race, higher education level, family history, and private insurance were associated with CPM. Of the 1569 (65.5%) patients without a high genetic risk or an identified mutation, 598 (39.3%) noted that their surgeon had recommended against the procedure—only 12 (1.9%) of these women then decided to go ahead with the surgery. However, among the 746 (46.8%) of women who did not receive a recommendation from their surgeon, 148 (19.0%) underwent CPM.

According to Jagsi, it’s not surprising that newly diagnosed breast cancer patients might find it difficult to absorb this complex information, considering the emotional upheaval they were going through at that time. “It seems logical that more aggressive surgery should be better at fighting disease—but that’s not how breast cancer works. It’s a real communication challenge,” she said.

The authors write that their survey showed patients are not very knowledgeable about CPM, and discussions with their surgeons were incomplete. Considering that women whose surgeons recommended against undergoing CPM primarily chose not to undergo the procedure indicates that effective patient-physician communication can reduce potential overtreatment.

Reference

Jagsi R, Hawley ST, Griffith KA, et al. Contralateral prophylactic mastectomy decisions in a population-based sample of patients with early-stage breast cancer [published December 21, 2016]. JAMA Surg. doi: 10.1001/jamasurg.2016.4749.