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SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
On Twitter @sherryboschert
This study asks the question, What motivates a woman with early-stage breast cancer to choose mastectomy, whether that be a unilateral mastectomy when she’s a candidate for breast conservation or the addition of a contralateral prophylactic mastectomy in the absence of an indication?
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The bottom line is that the diagnosis is met with fear and shock. When we present options in a very neutral, evidence-based way, we are talking to our patients about breast-conserving surgery and mastectomy. And we are, and we should be, talking about whether there’s a role for contralateral prophylactic surgery.
Bearing witness is something that needs to be understood here. A lot of the discussion that you have with your patients is going to be interpreted based on what those patients are hearing, seeing, and witnessing in their own lives. So, if Aunt Judy had breast-conserving surgery and died 5 years later, you’ve got to take that into account.
There is a desire for control. There is a need to reduce risks so it never happens to them again, and there is a desire to increase their odds of surviving. That comes down to patients’ decision-making experience, their reasons for choosing a surgery that is far more aggressive than it possibly should be, and their goal to control cancer. We’re seeing an increasing mastectomy rate – more surgery, more control.
There is a process of deliberation where we take many factors into consideration before determining what we want to do. The implication based on this abstract, I think, is whether clinicians need to identify the deliberations that are leading to a decision before acting surgically.
Dr. Covelli’s preliminary work suggests that decisions around surgery are incredibly complex, and ensuring decisions are informed is complicated. Learning how patients deliberate is important – what experiences and what social networks are informing that decision? (And I don’t mean Twitter and Facebook, I mean in patients’ own real, face-to-face lives.) What is the role of the preoperative work-up in influencing those deliberations? How is that preoperative MRI influencing these decisions, based on anything that potentially might be happening?
I think this is very provocative work that can go further. The take-home points for me: Engage cognitively, engage with evidence, engage with data, but you have to engage practically. You need to know: Where is that person hearing information that I’m not telling her? How is she processing that information with information that I have just given? Engage cognitively; engage affectively.
Dr. Don S. Dizon is a medical gynecologic oncologist and director of the oncology sexual health clinic at Massachusetts General Hospital, Boston. These are excerpts of his remarks as the discussant of Dr. Covelli’s study at the meeting. He disclosed that he has been employed by UpToDate.
This study asks the question, What motivates a woman with early-stage breast cancer to choose mastectomy, whether that be a unilateral mastectomy when she’s a candidate for breast conservation or the addition of a contralateral prophylactic mastectomy in the absence of an indication?
|
|
The bottom line is that the diagnosis is met with fear and shock. When we present options in a very neutral, evidence-based way, we are talking to our patients about breast-conserving surgery and mastectomy. And we are, and we should be, talking about whether there’s a role for contralateral prophylactic surgery.
Bearing witness is something that needs to be understood here. A lot of the discussion that you have with your patients is going to be interpreted based on what those patients are hearing, seeing, and witnessing in their own lives. So, if Aunt Judy had breast-conserving surgery and died 5 years later, you’ve got to take that into account.
There is a desire for control. There is a need to reduce risks so it never happens to them again, and there is a desire to increase their odds of surviving. That comes down to patients’ decision-making experience, their reasons for choosing a surgery that is far more aggressive than it possibly should be, and their goal to control cancer. We’re seeing an increasing mastectomy rate – more surgery, more control.
There is a process of deliberation where we take many factors into consideration before determining what we want to do. The implication based on this abstract, I think, is whether clinicians need to identify the deliberations that are leading to a decision before acting surgically.
Dr. Covelli’s preliminary work suggests that decisions around surgery are incredibly complex, and ensuring decisions are informed is complicated. Learning how patients deliberate is important – what experiences and what social networks are informing that decision? (And I don’t mean Twitter and Facebook, I mean in patients’ own real, face-to-face lives.) What is the role of the preoperative work-up in influencing those deliberations? How is that preoperative MRI influencing these decisions, based on anything that potentially might be happening?
I think this is very provocative work that can go further. The take-home points for me: Engage cognitively, engage with evidence, engage with data, but you have to engage practically. You need to know: Where is that person hearing information that I’m not telling her? How is she processing that information with information that I have just given? Engage cognitively; engage affectively.
Dr. Don S. Dizon is a medical gynecologic oncologist and director of the oncology sexual health clinic at Massachusetts General Hospital, Boston. These are excerpts of his remarks as the discussant of Dr. Covelli’s study at the meeting. He disclosed that he has been employed by UpToDate.
This study asks the question, What motivates a woman with early-stage breast cancer to choose mastectomy, whether that be a unilateral mastectomy when she’s a candidate for breast conservation or the addition of a contralateral prophylactic mastectomy in the absence of an indication?
|
|
The bottom line is that the diagnosis is met with fear and shock. When we present options in a very neutral, evidence-based way, we are talking to our patients about breast-conserving surgery and mastectomy. And we are, and we should be, talking about whether there’s a role for contralateral prophylactic surgery.
Bearing witness is something that needs to be understood here. A lot of the discussion that you have with your patients is going to be interpreted based on what those patients are hearing, seeing, and witnessing in their own lives. So, if Aunt Judy had breast-conserving surgery and died 5 years later, you’ve got to take that into account.
There is a desire for control. There is a need to reduce risks so it never happens to them again, and there is a desire to increase their odds of surviving. That comes down to patients’ decision-making experience, their reasons for choosing a surgery that is far more aggressive than it possibly should be, and their goal to control cancer. We’re seeing an increasing mastectomy rate – more surgery, more control.
There is a process of deliberation where we take many factors into consideration before determining what we want to do. The implication based on this abstract, I think, is whether clinicians need to identify the deliberations that are leading to a decision before acting surgically.
Dr. Covelli’s preliminary work suggests that decisions around surgery are incredibly complex, and ensuring decisions are informed is complicated. Learning how patients deliberate is important – what experiences and what social networks are informing that decision? (And I don’t mean Twitter and Facebook, I mean in patients’ own real, face-to-face lives.) What is the role of the preoperative work-up in influencing those deliberations? How is that preoperative MRI influencing these decisions, based on anything that potentially might be happening?
I think this is very provocative work that can go further. The take-home points for me: Engage cognitively, engage with evidence, engage with data, but you have to engage practically. You need to know: Where is that person hearing information that I’m not telling her? How is she processing that information with information that I have just given? Engage cognitively; engage affectively.
Dr. Don S. Dizon is a medical gynecologic oncologist and director of the oncology sexual health clinic at Massachusetts General Hospital, Boston. These are excerpts of his remarks as the discussant of Dr. Covelli’s study at the meeting. He disclosed that he has been employed by UpToDate.
SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
On Twitter @sherryboschert
SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
Major finding: Fear and a desire for control over cancer drove women to choose mastectomy.
Data source: A qualitative study of 30 women with early-stage breast cancer who were candidates for breast-conserving surgery but chose unilateral mastectomy with or without contralateral prophylactic mastectomy.
Disclosures: Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
