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Expert Discusses Recommending Against Prophylactic Mastectomy

Angelica Welch
Published: Friday, Apr 14, 2017

Steven J. Katz, MD

Steven J. Katz, MD

Desire to undergo a contralateral prophylactic mastectomy (CPM) has been rising in patients diagnosed with breast cancer in recent years. CPM is discouraged for patients without an elevated risk for a second primary breast cancer, as per surgical guidelines.

A population-based survey was conducted to examine the association between patient report of surgical recommendation against CPM and to what extent it was discussed with the surgeon. Three outcomes were considered: patient satisfaction with surgery decisions, receipt of a second opinion, and receipt of surgery by a second surgeon.

“Surgeons have been concerned about the rise in the use of this procedure, which is quite morbid—the removal of both breasts. They are not enthusiastic about performing this procedure in the tens of thousands of women who will receive it this year, and they are concerned about how to have this discussion with patients,” said lead author Steven J. Katz, MD.

Katz says that surgical recommendation against CPM did not seem to push patients to seek a second opinion or to switch surgeons. Although, findings did show that patients were less satisfied with surgical decision if the surgeon who recommended against CPM did not have a substantive discussion about it.

In an interview with OncLive, Katz, professor of medicine and health management and policy at the University of Michigan, discussed his study of patient reaction to surgeon recommendations about CPM.

OncLive: Could you provide some background on the rationale behind this study?

Katz: CPM for women with early-stage breast cancer is a major issue that has evolved over the past 5 to 7 years and the number of the women undergoing this most extensive surgical treatment has increased rather dramatically. This is probably related to more attention given to the procedure from famous people who got it, and with more women getting CPM in the community—newly diagnosed patients know of a daughter or mother or friend who have had it and are very happy with the fact that they feel that they are completely free of any future possibility of having the caner. The problem with this mindset is that many women getting CPM are at average risk for a second primary cancer. The risk of developing a secondary breast cancer is so low, given all of the other reasons, that CPM in average-risk women does not confer any benefit with regard to survival or even distant recurrence. Additionally, reconstructive surgery means more days lost at work and long-term quality-of-life issues related to not having the natural breast.

The study that we did was a large survey of patients, shortly after diagnosis, in Georgia and Los Angeles county, and we asked what their surgeons recommended and what their reaction was along 3 lines: did they get a second opinion, did they go to a different surgeon to get the operation if their first surgeon recommended against it, or did the suggestion affect their satisfaction with overall surgical decision making.

What we found was pretty reassuring—about one-third of women reported that their surgeons recommended against CPM. That report was not associated with a second opinion or losing the patient to a second surgeon. There was a little bit of dissatisfaction—women were more dissatisfied with their overall surgical decision, not based on the recommendation alone, but whether that was well discussed or not. If the recommendation was not well discussed, those patients were somewhat more dissatisfied with the overall surgical decision.

The conclusion of the paper was that there was a substantial amount of patients reporting that their surgeons are recommending against this most aggressive treatment, that it doesn't seem to be motivating patients to go to another surgeon, and that dissatisfaction with decision-making seems to be tied with the adequacy of discussion over exactly what recommendation is made. The pushback against this surgery does not seem to be causing a great discourse in the clinical encounter.

View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: How Do We Leverage PARP Inhibition Strategies in the Contemporary Treatment of Breast Cancer?May 31, 20191.5
Community Practice Connections™: A Better Way to Stop Pain: Paths Toward Responsible Postsurgical Pain Management for Patients With Breast CancerMay 31, 20191.5
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