December 22, 2016

Study Finds Striking Use of Double Mastectomy

ANN ARBOR, Mich -- December 22, 2016 -- Nearly half of patients with early-stage breast cancer considered having double mastectomy and 1 in 6 received it, including many who were at low risk of developing a second breast cancer, according to a study published online by JAMA Surgery.

Many patients who chose double mastectomy demonstrated little knowledge of the lack of benefit this aggressive procedure has for most patients.

“[The fact] that 1 in 6 patients with breast cancer chose bilateral mastectomy is really striking,” said Reshma Jagsi, MD, University of Michigan, Ann Arbor, Michigan. “We knew it was increasing, but I don't think many of us realised just how frequent this is.”

Contralateral prophylactic mastectomy has been increasing over the last decade, in part fuelled by celebrities’ stories and social media sharing. The aggressive procedure is often recommended for women at high risk of developing a second cancer, but for women at average risk, the surgery offers little benefit.

For the current study, the researchers surveyed 2,578 women from Georgia and California who had surgery for early-stage breast cancer in 1 breast. Overall, 44% said they considered double mastectomy.

Patients were grouped based on their genetic risk of developing cancer in the unaffected breast. A quarter of the higher risk patients underwent double mastectomy, and so did 14% of those at average risk.

Women were also asked whether contralateral prophylactic mastectomy improved survival or prevented cancer from returning. The answers demonstrated poor understanding of the surgery’s benefits.

Among patients who considered double mastectomy, only 38% knew it does not improve survival for all women with breast cancer. Almost all patients said peace of mind motivated them to choose double mastectomy.

“At a time when emotions are running high, it’s not surprising that newly diagnosed patients with breast cancer might find it difficult to absorb this complex information,” said Steven J. Katz, MD, University of Michigan. “It seems logical that more aggressive surgery should be better at fighting disease -- but that's not how breast cancer works. It's a real communication challenge.”

When patients perceived that their surgeons recommended strongly against contralateral prophylactic mastectomy, most heeded that advice and only 2% had the procedure. The rates were higher among women who perceived no surgeon recommendation, with 1 in 5 choosing the procedure, even if they were at average risk of a genetic mutation.

Because the study asked patients to report their surgeon’s recommendations, it’s possible some surgeons did recommend against double mastectomy but that patients failed to hear or understand.

“As physicians, we want to be respectful of our patients' preferences and values,” said Dr. Jagsi. “We don't want to alienate patients who are already in a stressful situation. We want them to trust us. When a patient comes in saying she has already decided on double mastectomy, it can be challenging to strike that balance between respecting her preferences and adequately conveying why the medical community in general doesn’t think it’s necessary.”

The study authors call for better communication training for physicians to help them navigate these difficult conversations more effectively.

SOURCE: University of Michigan Health System

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