Satisfaction With Surgical Decision-Making in Women Considering Contralateral Prophylactic Mastectomy for Breast Cancer
In a study reported in JAMA Surgery, Katz et al found that most patients considering contralateral prophylactic mastectomy for stage 0 to II breast cancer were satisfied with surgical decision-making. Most surgeons discussed contralateral prophylactic mastectomy and most did not recommend against it. Current guidelines recommend discouragement of contralateral prophylactic mastectomy in patients without an elevated risk for second primary breast cancer, based on family history and genetic risk.
Study Details
The population-based survey study was conducted among women identified through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County who had stage 0 to II breast cancer and were treated in 2013 or 2014. Surveys were sent approximately 2 months after surgery to 3,880 women, with 2,578 (71%) responding; of these responders, 1,140 with unilateral breast cancer who considered contralateral prophylactic mastectomy were included in the analysis.
Patents had a mean age of 56 years (56% < 60 years), 25% completed high school or less, 44% were nonwhite, and 60% were considered to be at high risk for recurrence. Overall, 57.5% considered contralateral prophylactic mastectomy strongly or very strongly (vs weakly or moderately), 41% underwent breast-conserving therapy, 22% underwent unilateral mastectomy (41% with breast reconstruction), and 38% underwent contralateral prophylactic mastectomy (77% with breast reconstruction). First surgeon recommendations were not against contralateral prophylactic mastectomy in 67% of cases and against contralateral prophylactic mastectomy in 27%; the surgeon discussed contralateral prophylactic mastectomy in 63% of cases and did not substantively discuss contralateral prophylactic mastectomy in 30%.
Satisfaction With Surgery Decisions
Overall, 7.6% of patients were dissatisfied with their surgical decision, 20.6% got a second opinion on surgical options, and 9.8% had surgery performed by a second surgeon. First surgeon recommendation against contralateral prophylactic mastectomy was associated with lower use of contralateral prophylactic mastectomy vs no recommendation against it (6.1% vs 57.5%, P < .01).
Dissatisfaction rates were higher among women whose surgeons recommended against contralateral prophylactic mastectomy (12.8% vs 6.5%, P < .01) and among those whose surgeons did not discuss it (13.5% vs 6.0%, P < .01). Dissatisfaction rates were 3.9% among patients with surgeons who did not recommend against contralateral prophylactic mastectomy but discussed it, 7.7% among those whose surgeons did not recommend against contralateral prophylactic mastectomy but did not substantively discuss it, 7.6% among those whose surgeons recommended against it with discussion, and 14.5% among those whose surgeons recommended against contralateral prophylactic mastectomy without discussion—a group representing 13% of the entire cohort (P < .01 across 4 groups).
Patients receiving a recommendation against contralateral prophylactic mastectomy were not more likely to seek a second opinion on surgery vs other patients (17.1% vs 15.1%, P = .52) and were not more likely to undergo surgery by a second surgeon (7.9% vs 8.3%, P = .88).
The investigators concluded: “Most patients are satisfied with surgical decision making. First-surgeon recommendation against [contralateral prophylactic mastectomy] does not appear to substantively increase patient dissatisfaction, use of second opinions, or loss of the patient to a second surgeon.”
The study was supported by the National Cancer Institute, California Department of Public Health, and Centers for Disease Control and Prevention.
Steven J. Katz, MD, MPH, of University of Michigan, Ann Arbor, is the corresponding author of the JAMA Surgery article.
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