Young Breast Cancer Patients and Surgical Decision-Making: Contralateral Prophylactic Mastectomy

Jan. 29, 2016

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Take-Home Message:

Women aged 40 and younger with breast cancer diagnoses have two options for surgical treatment: breast-conserving surgery (BCS), often referred to as lumpectomy, and unilateral mastectomy (UM). Contralateral prophylactic mastectomy (CPM) is often an additional therapy to consider. Increasingly, young breast cancer patients are choosing CPM as part of their surgical plans. This choice appears to be based on personal interpretations of recurrence risk and personal ideas of best treatment. Increased communication between a patient and her treatment team may alleviate her anxiety and promote shared decision-making between a woman and her physician. There is opportunity for providers to educate patients about the minimal impact of CPM on local, contralateral, and distant recurrence in most cases.

 

Summary

Local Therapy Decision-Making and Contralateral Prophylactic Mastectomy in Young Women with Early-Stage Breast Cancer

Authors: Rosenberg S, Sepucha K, Ruddy KJ, et al.
Source: Ann Surg Oncol. 2015;22:3809-3815.
www.ncbi.nlm.nih.gov/pubmed/25930247

This group selected 560 patients within their longitudinal study of women ≤40 years of age with breast cancer. These women were given questionnaires over 1 year to assess their satisfaction with and reasons for their breast cancer surgery choices. The goal was to find associations with the choice of CPM.

The median age at diagnosis was 37. Most women had early-stage (I or II) disease and most did not have a BRCA mutation. Overall, 42.9% of the respondents had a CPM. This value was lower when the BRCA mutation carriers were excluded.

CPM was performed in 59.9% of women who stated that their surgical choice was made on their own. The rate of CPM fell to 35.3% when the decision was made by the patient in consultation with her physician and to 5.6% when the surgical choice was made mainly by the recommendation her physician. The level of confidence with the decision was higher among those with CPM than those with breast-conserving surgery (BCS) or unilateral mastectomy (UM).

Compared to BCS or UM, women who chose CPM were more likely to be BRCA mutation carriers and to perceive their decision-making process as being a solitary one. These women were less worried about cancer recurrence and had greater confidence in their decision, compared to women who chose BCS or UM. On the other hand, women choosing CPM tended to have higher anxiety levels compared to women choosing UM or BCS. It was also noted that more than 90% of women who had CPM had reconstruction.

The group concluded that there was opportunity for increased patient education about the true and perceived benefits of CPM on breast cancer recurrence risk and survival. Increased physician involvement in a woman's decision-making process could reduce patient anxiety. These efforts would have an impact on the rate of CPM done for early-stage breast cancer in young women. However, they did note evidence that the decision is often based on personal "peace of mind," which cannot be easily measured or applied evenly to every patient. The high rate of reconstruction among patients choosing CPM suggests a possible desire for breast symmetry in addition to cancer treatment and recurrence risk reduction.

American Society of Breast Surgeons Consensus Statements on Contralateral Prophylactic Mastectomy:
http://link.springer.com/article/10.1245/s10434-016-5443-5
http://link.springer.com/article/10.1245/s10434-016-5408-8