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Should women be required to meet specific risk criteria to undergo contralateral prophylactic mastectomy?
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Yes.
Rates of contralateral prophylactic mastectomy (CPM) among women in the United States with unilateral breast cancer have been increasing, and this trend shows no signs of slowing down.
This is despite the fact that the majority of women will obtain no oncologic benefit from CPM.
The significance of this trend was highlighted when the American Board of Internal Medicine’s Choosing Wisely campaign recently included the statement: Do not routinely perform a double mastectomy in patients who have a single breast with cancer.
With this initiative, and in response to this trend, it is crucial for us to consider specific baseline risk criteria for women to undergo CPM. Although recognizing that there are women who will benefit from CPM from an oncologic standpoint — such as those with genetic mutations — there is still room to influence decisions for CPM, many of which are based in fear.
Drivers for CPM are varied. They include influence of the media, fear of recurrence, poor understanding of the risks for relapse and contralateral breast cancer, and the risks associated with breast reconstruction. Wouldn’t specific risk criteria help inform patients in this frightening and confusing time?
Risk criteria should identify patients at higher risk for complications, local recurrence from their current cancer and future development of contralateral breast cancer. Factors that need to be considered in this decision include family history, patient age, comorbidities and tumor prognosis, as well as the initial plan for surgery, systemic therapy and radiotherapy.
Potential comorbidities that may increase the likelihood of complications — such as cardiac and pulmonary comorbidities, obesity, diabetes, smoking, and use of steroids or anticoagulants — should be considered when establishing risk criteria, as CPM can double the risk for complications.
Patients who undergo CPM can have longer delays to adjuvant therapy than those who undergo unilateral mastectomy or lumpectomy. Therefore, the need for adjuvant chemotherapy or radiation needs to be considered in this decision.
By identifying these factors, we can establish risk criteria that can provide additional educational resources for both surgeons and patients.
In addition, as we look to decrease variations in the care of patients with cancer, we must recognize that there are significant differences in rates of CPM among surgeons. Acknowledging that this decision is extremely complex, with specific risk criteria, we take a step toward minimizing this variation and better understanding its utilization.
By establishing criteria, we do not take away from the importance of shared decision-making between physician and patient. Instead, hopefully we inject meaningful information into the conversation between a surgeon and the newly diagnosed patient with breast cancer.
References:
Choosing Wisely. American Society of Breast Surgeons. 2016. Available at: www.choosingwisely.org/clinician-lists/breast-surgeons-mastectomies-for-single-breast-cancer-patients. Accessed on Sept. 28, 2016.
Covelli AM, et al. Ann Surg Oncol. 2015;doi:10.1245/s10434-014-4033-7.
Rosenberg SM and Partridge AH. JAMA Surg. 2014;doi:10.1001/jamasurg.2013.5713.
Sharpe SM, et al. Ann Surg Oncol. 2014;doi:10.1245/s10434-014-3687-5.
Carla S. Fisher, MD, is assistant professor of surgery at Hospital of the University of Pennsylvania. She can be reached at carla.fisher@uphs.upenn.edu. Disclosure: Fisher reports no relevant financial disclosures.
No.
The decision that confronts patients with breast cancer about the disparate surgical treatment options is very complex.
In addition, it comes at a time that is emotionally charged when communication between the health care team and the patient can be difficult.
Women are increasingly opting for bilateral mastectomy, and the national rates of contralateral prophylactic mastectomy (CPM) are trending upward in the United States. When discussing the role of CPM with a patient, many factors must be taken into account. These include patient age and comorbidities, family history and genetic testing results, risk for a second primary breast cancer, risk for distant recurrence from the primary tumor and surgical risks associated with the prophylactic procedure.
After considering all of these factors, there are multiple reasons why women may choose a CPM, but the predominant theme for many is peace of mind.
So, is peace of mind reason enough to proceed, or should women have to meet certain criteria to qualify for a CPM?
I would argue that identifying specific risk criteria would not only be incredibly difficult, as each patient’s journey is unique to them, but that it would create an environment whereby algorithmic checklists trump patient autonomy.
Further, it would stifle the art of breast surgical practice. The cornerstones of a shared decision-making process are education of the patient and communication. The patient needs to be involved in the decision-making process and must be given the time to reflect on those choices so that the treatment selected reflects her personal values and goals.
One of the most rewarding aspects of my day is developing that relationship and arriving at the best treatment decision for each woman.
The decision of whether to pursue CPM is difficult. The American Society of Breast Surgeons’ consensus panel guidelines are a tremendous resource to help guide and frame the discussion. However, at the end of the day, we need to support and respect the patient’s decision.
Measured maternalism/paternalism can aid the interaction, but ultimately it has little place in the breast surgeon’s office. Instead, the ultimate goal is to deliver an unbiased view of the relevant data so that the patient can be empowered to reach a high-quality, shared decision. For some, peace of mind should be enough.
References:
Boughey JC, et al. Ann Surg Oncol. 2016;doi:10.1245/s10434-016-5408-8.
Boughey JC, et al. Ann Surg Oncol. 2016;doi:10.1245/s10434-016-5443-5.
Molenaar S, et al. Br J Cancer. 2004;90:2123-2130.
Steiner CA, et al. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. 2016. Available at: www.ncbi.nlm.nih.gov/pubmed/27253008. Accessed on Sept. 28, 2016.
Julie A. Margenthaler, MD, FACS, is professor of surgery at Washington University School of Medicine in St. Louis. She can be reached at margenthalerj@wudosis.wustl.edu. Disclosure: Margenthaler reports no relevant financial disclosures.