Surgeons greatly influence likelihood of contralateral prophylactic mastectomy
Women with breast cancer appeared three times more likely to undergo contralateral prophylactic mastectomy if their attending surgeon was less reluctant to perform the surgery, according to results of a population-based survey study.
“Surgeons have huge influence on treatment, and with that comes ultimate responsibility to get it right with patients, even with a procedure that seems to be driven largely by patient preference,” Steven J. Katz, MD, MPH, professor of medicine and of health management and policy at University of Michigan, said in a press release.
Consensus statements from professional associations agree that contralateral prophylactic mastectomy should only be considered among patients with high risk for second primary breast cancer, and discouraged among patients at average risk. However, only one-third of patients at average risk who wanted contralateral prophylactic mastectomy reported that their surgeon discouraged them from undergoing the procedure.
No prior study has evaluated an attending surgeon’s influence on variations in receipt of contralateral prophylactic mastectomy.
Therefore, Katz and colleagues sought to determine how much influence a surgeon has on patient decision-making.
Researchers evaluated data from the Georgia and Los Angeles County SEER registries to identify women aged 20 to 79 years (mean, 61.9 years) who were diagnosed with ductal carcinoma in situ or invasive breast cancer and participated in the iCanCare study. Researchers sent surveys requesting patient covariates — such as age, risk for second primary breast cancer and genetic testing results — to 7,810 patients, of whom 5,080 completed the survey.
Most patients (98%) reported having an attending surgeon.
Researchers also sent surveys to 488 attending surgeons requesting information such as age, annual number of newly diagnosed breast cancer patients treated, years in practice and sex, as well as what kind of treatment they would recommend for the typical patient. About three-quarters of surgeons responded (77%; n = 377).
Survey responses indicated 28% of patients had an increased risk for second primary cancer and 16% underwent contralateral prophylactic mastectomy.
Fifty-two percent of surgeons reported being in medical practice for more than 20 years, and 30% treated more than 50 new patients with breast cancer annually.
Independent of age, diagnosis date, BRCA status and risk for second primary cancer, the likelihood of a patient undergoing contralateral prophylactic mastectomy increased nearly threefold (OR = 2.8; 95% CI, 2.1-3.4) if the patient saw a surgeon with a practice approach one standard deviation above the mean contralateral prophylactic mastectomy rate.
In 25% of cases, surgeon influence on contralateral prophylactic mastectomy appeared related to the surgeon’s attitudes about initial recommendations for surgery and responses to patient requests.
“Two attitudes seem to explain the difference: how strongly the surgeon favors breast-conserving surgery and how reluctant the surgeon is to perform contralateral prophylactic mastectomy,” Katz said.
The rate of contralateral prophylactic mastectomy increased for surgeons who reported being least favorable of initial breast conservation and least reluctant to perform the surgery compared with surgeons who favored breast conservation and were more reluctant to perform contralateral prophylactic mastectomy (34% vs. 4%).
“That difference is huge,” Katz said. “Even for a procedure that is very patient driven, we see that surgeons account for a lot of the variability in the community and those surgeon attitudes really matter in terms of whether a patient does or does not get contralateral prophylactic mastectomy.”
Because surgeons have a large influence on patient decision-making, communication tools are needed to assist in guiding the patient through informed discussions about all treatment options, Julie A. Margenthaler, MD, professor of endocrine and oncologic surgery, and Amy E. Cyr, MD, assistant professor of surgery in the section of endocrine and oncologic surgery, both from Washington University School of Medicine in St. Louis, wrote in an accompanying editorial.
“It is our opinion that variability in communication and the lack of tools and resources to guide the surgical discussion have created disparate patient experiences,” they wrote. “When a patient has a preexisting desire for contralateral prophylactic mastectomy, we need to dispel the potential myths surrounding her reflective decision and ensure she that she fully understands the risks and benefits (and lack of survival).”
A clinical trial is underway to develop a communication tool that could positively impact the way surgeons counsel patients.
“The goal is to standardize the methods and information patients receive to ensure that their decisions are based on facts, not fear,” Margenthaler and Cyr wrote. – by Melinda Stevens
Disclosures: The researchers and editorial authors report no relevant financial disclosures.