July 29, 2016
3 min read

American Society of Breast Surgeons recommends against contralateral prophylactic mastectomy

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The American Society of Breast Surgeons issued a position statement that recommends against contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer.

In its statement — published in Annals of Surgical Oncology — the society encouraged an evidence-based, patient value-focused approach to determine the value of contralateral prophylactic mastectomy in patients with breast cancer.

Judy Boughey, MD

Judy C. Boughey

“This consensus statement examines and summarizes the data, offers guidelines about appropriateness of prophylactic surgery and provides a framework for patient discussion,” Judy C. Boughey, MD, FACS, professor of surgery at Mayo Clinic in Rochester, Minnesota, and lead author of the position statement, said in a press release. “When discussing contralateral prophylactic mastectomy with patients, it is important for patients to understand it does not improve their cancer outcome. [It also is important] for them to understand the pros, cons and alternatives to contralateral prophylactic mastectomy.”

The recommendation addressed the growing trend of contralateral prophylactic mastectomy, the removal of the healthy breast in women who undergo mastectomy for breast cancer.

Although the procedure is appropriate for certain high-risk groups, research has shown the majority of women who undergo contralateral prophylactic mastectomy derive no oncological benefit.

The society panel that developed the position statement noted that, for most women, the estimated risk of developing cancer in the opposite breast is 2% to 6% over the subsequent decade. Also, contralateral prophylactic mastectomy does not improve the cure rate of the known cancer, nor reduce the risk for its recurrence.

“Typically, the decision to perform a contralateral procedure is based on a combination of the patient’s perceived risk and fear of future breast cancer, anxiety about annual screening and possible additional diagnostic procedures, as well as the uncertainty of physical, emotional and cosmetic surgical outcomes,” Julie A. Margenthaler, MD, FACS, professor in the division of surgery at Washington University School of Medicine, said in the release.

“The society believes that a final treatment plan should be based largely on an analysis of the risks and benefits of contralateral mastectomy and the patient’s perspective on surgery,” Margenthaler added. “Patient education on those risks and benefits, all treatment options and recurrence risks are crucial. A well-planned patient-surgeon discussion to facilitate this is extremely important.”

Deanna J. Attai

The consensus statement concluded contralateral prophylactic mastectomy:

Should be considered for women at significant risk for contralateral breast cancer. These include those with BRCA1 or BRCA2 mutations, those with strong family history of the disease, and those with a history of mantle chest radiation prior to age 30 years;

May be considered for those with other genetic risks, as well as for women who do not have genetic risks but do have strong family histories of breast cancer.

May be appropriate in other cases, such as to limit contralateral breast surveillance, improve reconstructed breast symmetry, manage risk aversion or manage extreme anxiety; and

Should be discouraged for women at average risk with unilateral breast cancer or advanced index cancer, those at high risk for surgical complications, and women who tested BRCA–negative but have a family member who carries a BRCA mutation.

The American Society of Breast Surgeons previously recommended against routine use of double mastectomy in patients who have a single breast cancer as part of its contribution to the American Board of Internal Medicine’s Choosing Wisely campaign. The initiative — designed to reduce spending without sacrificing quality care — encourages physicians and patients to have conversations about tests and procedures that are frequently offered but are not supported by evidence.

Instead, the society encouraged a shared decision-making process in which women should be counseled on the potential long-term outcomes on body image and sexuality, and provided with additional educational resources on risks and benefits, stronger patient engagement and enhanced decision-making guidelines.

“Contralateral prophylactic mastectomy counseling should include discussion of contralateral prophylactic mastectomy, risks of contralateral prophylactic mastectomy [and] rates of contralateral breast cancer,” Boughey and colleagues wrote. “[It also should] ensure patients are engaged in the decision-making, and making decisions that are concordant with their treatment preferences and personal values.”

The society’s statement emphasized that performance of contralateral prophylactic mastectomy is not an appropriate quality measure. Because the procedure is not associated with improved outcomes, if it is typically considered unnecessary or adding significant risk, quality scoring may limit access for those who could derive the greatest benefit.

“Counseling patients about contralateral prophylactic mastectomy and refinement of patient-surgeon decision-making models is one of the best ways we can help women make medically sound choices with comfort and confidence,” Deanna J. Attai, MD, assistant clinical professor of surgery at David Geffen School of Medicine at UCLA and the society’s immediate past president, said in the release.

Disclosures: The researchers report no relevant financial disclosures.