Recently released data from the Agency for Healthcare Research and Quality (AHRQ) showed that the rate of mastectomies increased between 2005 and 2013, with much of that increase attributed to bilateral mastectomies among women with early-stage cancer in one breast opting for bilateral mastectomies. The increased rate of bilateral mastectomies among these women is both “perplexing” and alarming,” Ismail Jatoi, MD, PhD, said in an interview with The ASCO Post. Dr. Jatoi is Professor and Chief of Surgical Oncology and holds the Dale H. Dorn Endowed Chair in Surgery at The University of Texas Health Science Center, San Antonio.

It is perplexing, he said, because “the risk of contralateral breast cancer is decreasing due to better drug therapy.” It is “alarming,” he said, because for many patients with unilateral breast cancer, “lumpectomy would be the better option in preserving quality of life.”

Why Choose Contralateral Mastectomy?

So why do women who can be treated effectively with lumpectomy choose contralateral prophylactic mastectomy?

“There are multiple reasons,” Dr. Jatoi said, and “ongoing studies are trying to get to the bottom of this.” Among the possible reasons may be anxiety about cancer developing in the opposite breast. “People may overestimate their risk of developing contralateral breast cancer,” which, as noted earlier, is decreasing because of better drug therapy.

Some women may be concerned about symmetry and the belief that better symmetry might be achieved with bilateral mastectomy and breast reconstruction. “If symmetry is the issue, there are other options besides bilateral mastectomy,” Dr. Jatoi noted. “You can go undergo mastopexy—a breast lift—for example, where you achieve symmetry without having a bilateral mastectomy and reconstruction.”

In addition, false-positives from enhanced imaging with preoperative magnetic resonance imaging “may increase alarm and result in unnecessary bilateral mastectomy,” Dr. Jatoi said.

Increased genetic testing is also a factor. “Some patients with unilateral breast cancer will undergo genetic testing and find that they are BRCA-mutation carriers; they may elect to undergo a bilateral mastectomy,” Dr. Jatoi said. For women with unilateral breast cancer with BRCA or other mutations, choosing to have a bilateral mastectomy “is probably justifiable,” Dr. Jatoi said. That is a small proportion of the overall number of women opting for bilateral mastectomy, he added.

Alleviating the Alarm

“The vast majority of these patients don’t have mutations,” Dr. Jatoi pointed out. And for this vast majority, Dr. Jatoi said, “I don’t advise patients to have a bilateral mastectomy for unilateral breast cancer. I think most surgical oncologists don’t, because there is no reason for it. It doesn’t make that much sense, when rates of contralateral breast cancer are decreasing in women with unilateral breast cancer,” he continued.

“Much of the alarm can be alleviated with a good discussion. When you point out, for example, that rates of contralateral breast cancer are decreasing—and they are very, very low—that can alleviate some of the concerns that patients may have.” ■

Disclosure: Dr. Jatoi reported no potential conflicts of interest.