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Fear seems to be a major driver of contralateral prophylactic mastectomy after initial breast cancer surgery.
Almost two-thirds of those who had the procedure had no clinical indication for it, Sarah T. Hawley, Ph.D., and her colleagues wrote in the May 21 online issue of JAMA Surgery (doi:10.1001/jamasurg.2013.5689). The women choosing contralateral prophylactic mastectomy (CPM) for which there was no clinical indication were more highly educated than were those who didn’t elect the surgery, more likely to be white, and two to four times more likely to be worried about a recurrence.
Fear of recurrence was a "powerful nonclinical factor" in the analysis, wrote Dr. Hawley of the University of Michigan, Ann Arbor – and education may be the best way to overcome it.
"A patient’s decision to undergo contralateral prophylactic mastectomy based on a strong fear of recurrence in the absence of clinical indications presents an important clinical challenge for surgeons," she and her colleagues wrote. "Growing literature supports the notion that patients have a difficult time assessing and interpreting their own risk and that fear and anxiety related to disease recurrence often supersede accurate risk perceptions to drive health decisions."
Dr. Hawley and her coinvestigators extracted their data from the Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit. They included records from 1,447 women aged 20-79 years who had been diagnosed with a first incident primary ductal carcinoma in situ or invasive breast cancer of stages I-IIIa.
About half of the sample was white; 21% was black, and 30% Hispanic. Other groups made up the balance. More than half (59%) had achieved some college-level education.
About half the respondents (57%) underwent breast-conserving surgery (BCS). Other surgical treatments included unilateral mastectomy (UM; 34%), and contralateral prophylactic mastectomy (8%).
CPM was pondered more frequently than it was an executed, the investigators said, with 19% of the entire sample considering it "strongly or very strongly."
Most of the women who had CPM said that they did it to prevent recurrence, with 78% citing that worry as a very important driver of their decision. However, the authors said, of the 106 women who underwent CPM, only 31% had clinical indications, while the majority (67%) did not.
A multivariate analysis determined the relationships between patient characteristics and breast surgery,
Those with some college-level education were five times more likely to have CPM than UM, and four times more likely to have that than BCS. Those with high worry were almost three times more likely to have CPM than UM, and four times more likely to have CPM than BCS.
Women who had positive genetic testing were 10 times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and 19 times more likely to have CPM than BCS. But those with negative results were still twice as likely to have the CPM as either of the other surgeries.
Having at least two close relatives with breast or ovarian cancer also significantly increased the likelihood of a CMP vs. UM (relative risk = 5) or BCS (RR = 4). Having had a diagnostic MRI doubled the chance of having CPM, compared with the other surgeries.
"Our results provide evidence that decisions about CPM represent a clear case in which better strategies to increase patient knowledge about their own risk of developing contralateral cancer as well as the net benefit of treatment are needed and should be made only after patients are accurately informed about these issues," Dr. Hawley and her coauthors said, adding that such patients need to clearly understand the consequences of CMP, "including lengthy recovery time and increased risk for serious operative complications."
The National Institutes of Health and the University of Michigan supported the study. Neither Dr. Hawley nor her coauthors had any financial disclosures.
On Twitter @alz_gal
Decisions about breast cancer surgery are often done when emotions run high, and when real comprehension of the long-term effects might be difficult, Dr. Shoshana Rosenberg wrote in an accompanying editorial.
"Anxiety and fear hamper optimal decision making, and greater psychological and emotional support may prove valuable in this situation."
Treatment decisions built on fear put surgeons in a tough spot, forcing them to balance their clinical knowledge of recurrence and surgical risk against the need to respect patients’ own desires. "While CPM might be considered overtreating women without clinical indications, it might still be the right choice for some women for risks reduction, cosmetic, and/or emotional reasons."
The earlier education about these issues, commences, the better incorporated it can become into this journey.
"Not only should the 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. ... Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike."
Dr. Rosenberg is a research fellow at the Dana Farber Cancer Institute, Boston. She had no financial disclosures.
Decisions about breast cancer surgery are often done when emotions run high, and when real comprehension of the long-term effects might be difficult, Dr. Shoshana Rosenberg wrote in an accompanying editorial.
"Anxiety and fear hamper optimal decision making, and greater psychological and emotional support may prove valuable in this situation."
Treatment decisions built on fear put surgeons in a tough spot, forcing them to balance their clinical knowledge of recurrence and surgical risk against the need to respect patients’ own desires. "While CPM might be considered overtreating women without clinical indications, it might still be the right choice for some women for risks reduction, cosmetic, and/or emotional reasons."
The earlier education about these issues, commences, the better incorporated it can become into this journey.
"Not only should the 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. ... Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike."
Dr. Rosenberg is a research fellow at the Dana Farber Cancer Institute, Boston. She had no financial disclosures.
Decisions about breast cancer surgery are often done when emotions run high, and when real comprehension of the long-term effects might be difficult, Dr. Shoshana Rosenberg wrote in an accompanying editorial.
"Anxiety and fear hamper optimal decision making, and greater psychological and emotional support may prove valuable in this situation."
Treatment decisions built on fear put surgeons in a tough spot, forcing them to balance their clinical knowledge of recurrence and surgical risk against the need to respect patients’ own desires. "While CPM might be considered overtreating women without clinical indications, it might still be the right choice for some women for risks reduction, cosmetic, and/or emotional reasons."
The earlier education about these issues, commences, the better incorporated it can become into this journey.
"Not only should the 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. ... Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike."
Dr. Rosenberg is a research fellow at the Dana Farber Cancer Institute, Boston. She had no financial disclosures.
Fear seems to be a major driver of contralateral prophylactic mastectomy after initial breast cancer surgery.
Almost two-thirds of those who had the procedure had no clinical indication for it, Sarah T. Hawley, Ph.D., and her colleagues wrote in the May 21 online issue of JAMA Surgery (doi:10.1001/jamasurg.2013.5689). The women choosing contralateral prophylactic mastectomy (CPM) for which there was no clinical indication were more highly educated than were those who didn’t elect the surgery, more likely to be white, and two to four times more likely to be worried about a recurrence.
Fear of recurrence was a "powerful nonclinical factor" in the analysis, wrote Dr. Hawley of the University of Michigan, Ann Arbor – and education may be the best way to overcome it.
"A patient’s decision to undergo contralateral prophylactic mastectomy based on a strong fear of recurrence in the absence of clinical indications presents an important clinical challenge for surgeons," she and her colleagues wrote. "Growing literature supports the notion that patients have a difficult time assessing and interpreting their own risk and that fear and anxiety related to disease recurrence often supersede accurate risk perceptions to drive health decisions."
Dr. Hawley and her coinvestigators extracted their data from the Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit. They included records from 1,447 women aged 20-79 years who had been diagnosed with a first incident primary ductal carcinoma in situ or invasive breast cancer of stages I-IIIa.
About half of the sample was white; 21% was black, and 30% Hispanic. Other groups made up the balance. More than half (59%) had achieved some college-level education.
About half the respondents (57%) underwent breast-conserving surgery (BCS). Other surgical treatments included unilateral mastectomy (UM; 34%), and contralateral prophylactic mastectomy (8%).
CPM was pondered more frequently than it was an executed, the investigators said, with 19% of the entire sample considering it "strongly or very strongly."
Most of the women who had CPM said that they did it to prevent recurrence, with 78% citing that worry as a very important driver of their decision. However, the authors said, of the 106 women who underwent CPM, only 31% had clinical indications, while the majority (67%) did not.
A multivariate analysis determined the relationships between patient characteristics and breast surgery,
Those with some college-level education were five times more likely to have CPM than UM, and four times more likely to have that than BCS. Those with high worry were almost three times more likely to have CPM than UM, and four times more likely to have CPM than BCS.
Women who had positive genetic testing were 10 times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and 19 times more likely to have CPM than BCS. But those with negative results were still twice as likely to have the CPM as either of the other surgeries.
Having at least two close relatives with breast or ovarian cancer also significantly increased the likelihood of a CMP vs. UM (relative risk = 5) or BCS (RR = 4). Having had a diagnostic MRI doubled the chance of having CPM, compared with the other surgeries.
"Our results provide evidence that decisions about CPM represent a clear case in which better strategies to increase patient knowledge about their own risk of developing contralateral cancer as well as the net benefit of treatment are needed and should be made only after patients are accurately informed about these issues," Dr. Hawley and her coauthors said, adding that such patients need to clearly understand the consequences of CMP, "including lengthy recovery time and increased risk for serious operative complications."
The National Institutes of Health and the University of Michigan supported the study. Neither Dr. Hawley nor her coauthors had any financial disclosures.
On Twitter @alz_gal
Fear seems to be a major driver of contralateral prophylactic mastectomy after initial breast cancer surgery.
Almost two-thirds of those who had the procedure had no clinical indication for it, Sarah T. Hawley, Ph.D., and her colleagues wrote in the May 21 online issue of JAMA Surgery (doi:10.1001/jamasurg.2013.5689). The women choosing contralateral prophylactic mastectomy (CPM) for which there was no clinical indication were more highly educated than were those who didn’t elect the surgery, more likely to be white, and two to four times more likely to be worried about a recurrence.
Fear of recurrence was a "powerful nonclinical factor" in the analysis, wrote Dr. Hawley of the University of Michigan, Ann Arbor – and education may be the best way to overcome it.
"A patient’s decision to undergo contralateral prophylactic mastectomy based on a strong fear of recurrence in the absence of clinical indications presents an important clinical challenge for surgeons," she and her colleagues wrote. "Growing literature supports the notion that patients have a difficult time assessing and interpreting their own risk and that fear and anxiety related to disease recurrence often supersede accurate risk perceptions to drive health decisions."
Dr. Hawley and her coinvestigators extracted their data from the Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit. They included records from 1,447 women aged 20-79 years who had been diagnosed with a first incident primary ductal carcinoma in situ or invasive breast cancer of stages I-IIIa.
About half of the sample was white; 21% was black, and 30% Hispanic. Other groups made up the balance. More than half (59%) had achieved some college-level education.
About half the respondents (57%) underwent breast-conserving surgery (BCS). Other surgical treatments included unilateral mastectomy (UM; 34%), and contralateral prophylactic mastectomy (8%).
CPM was pondered more frequently than it was an executed, the investigators said, with 19% of the entire sample considering it "strongly or very strongly."
Most of the women who had CPM said that they did it to prevent recurrence, with 78% citing that worry as a very important driver of their decision. However, the authors said, of the 106 women who underwent CPM, only 31% had clinical indications, while the majority (67%) did not.
A multivariate analysis determined the relationships between patient characteristics and breast surgery,
Those with some college-level education were five times more likely to have CPM than UM, and four times more likely to have that than BCS. Those with high worry were almost three times more likely to have CPM than UM, and four times more likely to have CPM than BCS.
Women who had positive genetic testing were 10 times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and 19 times more likely to have CPM than BCS. But those with negative results were still twice as likely to have the CPM as either of the other surgeries.
Having at least two close relatives with breast or ovarian cancer also significantly increased the likelihood of a CMP vs. UM (relative risk = 5) or BCS (RR = 4). Having had a diagnostic MRI doubled the chance of having CPM, compared with the other surgeries.
"Our results provide evidence that decisions about CPM represent a clear case in which better strategies to increase patient knowledge about their own risk of developing contralateral cancer as well as the net benefit of treatment are needed and should be made only after patients are accurately informed about these issues," Dr. Hawley and her coauthors said, adding that such patients need to clearly understand the consequences of CMP, "including lengthy recovery time and increased risk for serious operative complications."
The National Institutes of Health and the University of Michigan supported the study. Neither Dr. Hawley nor her coauthors had any financial disclosures.
On Twitter @alz_gal
FROM JAMA SURGERY
Key clinical point: Fear of breast cancer recurrence results in many unnecessary contralateral prophylactic mastectomies.
Major finding: Women with high worry levels about recurrence were almost three times more likely to have contralateral prophylactic mastectomy than unilateral mastectomy, and four times more likely to have it than breast-conserving surgery.
Data source: The database review comprised 1,447 women.
Disclosures: The National Institutes of Health and University of Michigan funded the studies. None of the authors had any financial disclosures.
