In the Journals

Contralateral prophylactic mastectomy often used unnecessarily

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August 28, 2016

Fear of recurrence drove many women with breast cancer to consider or undergo contralateral prophylactic mastectomy even when they were not at significant risk for contralateral occurrence, according to an analysis of SEER data.

"Women appear to be using worry over cancer recurrence to choose contralateral prophylactic mastectomy,” researcher Sarah Hawley, PhD, MPH, associate professor of internal medicine at the University of Michigan Medical School, said in a press release. “This does not make sense, because having a non-affected breast removed will not reduce the risk of recurrence in the affected breast. For women who do not have a strong family history or a genetic finding, we would argue it's probably not appropriate to get the unaffected breast removed.”

Hawley and colleagues conducted a longitudinal survey of 1,536 women who were newly diagnosed with breast cancer and were registered in the 2005 to 2007 Detroit and Los Angeles SEER registry. Follow-up surveys were conducted 4 years later.

The analytic sample included 1,447 women, 18.9% of whom strongly considered contralateral prophylactic mastectomy and 7.6% of whom underwent the procedure.

Many women who strongly considered contralateral mastectomy received it (32.2%), whereas 45.8% underwent unilateral mastectomy and 22.8% underwent breast conversation surgery.

A majority of women who underwent contralateral prophylactic mastectomy did not have major genetic or familial risk factors for contralateral occurrence (68.9%), and most women indicated worry about recurrence affected their decision (78.1%).

Researchers determined several factors were significantly associated with the decision to undergo contralateral prophylactic mastectomy rather than unilateral mastectomy or breast-conserving surgery. Those factors included receipt of positive genetic testing (RR ratio=10.48; 95% CI, 3.61-30.48), a strong family history of breast or ovarian cancers (RR ratio=5.19; 95% CI, 2.34-11.56), receipt of MRI (RR ratio=2.07; 95% CI, 1.21-3.52), a higher level of education (RR ratio=5.04; 95% CI, 2.37-10.71) and high levels of worry about recurrence (RR ratio=2.81; 95% CI, 1.14-6.88).

In order to address the possibility of overtreatment, shared decision making is necessary before patients undergo contralateral prophylactic mastectomy, Shoshana M. Rosenberg, ScD, MPH and Ann H. Partridge, MD, MPH, both of Dana-Farber Cancer Institute, wrote in an accompanying editorial.

“Not only should pros and cons of different treatment options be communicated, but there needs to be consideration of the patient’s personal circumstances and perceptions, all the while addressing anxiety and concerns about breast cancer recurrence and new primary disease (and the distinction between the two),” Rosenberg and Partridge wrote. “Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike.”

For more information:

Rosenberg SM. JAMA Surg. 2014;doi:10.1001/jamasurg.2013.5713.

Hawley ST. JAMA Surg. 2014;doi:10.1001/jamasurg.2013.5689.

Disclosure: The researchers report no relevant financial disclosures.

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