By Sandra Basu
ANN ARBOR, MI — Are healthcare providers doing enough to educate and advise breast cancer patients on their options, thereby avoiding unnecessary contralateral prophylactic mastectomy?
New research raises questions about the process leading to often unnecessary surgery.
A study led by Sarah Hawley, PhD, a research investigator at the Ann Arbor VA Center of Excellence in Clinical Care Management Research, noted that about 70% of women who have both breasts removed following a breast cancer diagnosis do so even though they face a very low risk of cancer in the healthy breast. The findings were presented at the American Society of Clinical Oncology’s Quality Care Symposium in November 2012.1
“There seems to be some knowledge gaps related to the procedure options that women choose between, and there also seems to be this real fear of breast cancer coming back that seems to be pervasive, regardless of the kinds of treatments that women get and regardless of the likelihood of their cancer coming back,” Hawley, who is also associate professor of internal medicine at the University of Michigan Medical School, told U.S. Medicine.
Contralateral prophylactic mastectomies generally are not recommended for consideration unless there is a family history of multiple members with breast or ovarian cancer or the patient has a positive genetic test for mutations in the BRCA1 or BRCA2 genes. In fact, one 2010 study published in the Journal of the National Cancer Institute suggested that CPM offered a small improvement in five-year breast cancer-specific survival only in young women with early-stage ER-negative breast cancer.
Despite that, research indicates that the procedure has not waned in popularity. A 2010 study published in the Annals of Surgical Oncology found that patients choosing preventive removal of the unaffected breast grew from 0.4% in 1998, to 4.7% in 2007. 2
Hawley said that, for the study, she and her co-authors looked at 1,446 women who had been treated for breast cancer and who had not had a recurrence. They found that 7% of women had surgery to remove both breasts. Nearly 1 in 5 had a double mastectomy among the women who had a mastectomy.
“We had a sample of 1,450 women who were in this analysis and of those 110 had a double mastectomy. When we looked at the group that got double mastectomy, 30% of them had a clinical indication, which we defined as having a genetic mutation and/or having a very strong family history, which would be two or more first degree relatives with breast or ovarian cancer,” Hawley pointed out. “The other 70% didn’t have either of those factors.”
As part of the study, researchers asked the women how much worry about cancer recurrence figured in their decision process. The study found that 90% of women who had surgery to remove both breasts reported being very worried about the cancer recurring.
Hawley noted that, except for those who have a genetic mutation or strong family history, removing the second breast likely is of little benefit.
“It is really not helping them in terms of their survival of this disease to get their breast removed. One would expect that would not be recommended, because that is yet another surgery with the potential for complications and recovery time that you wouldn’t want to embark on if you didn’t need it,” she said.
Hawley said the “million-dollar question” is what kind of discussion occurred between clinicians and the 70% of patients who chose a double mastectomy without a clinical indication. She suggests, however, that it is highly unlikely that a double mastectomy was recommended by their physician.
If one or more of the following features are present in a family, hereditary breast and ovarian cancer (HBOC) resulting from germ line mutations in BRCA1 and BRCA2 is suspected and further risk evaluation is warranted.
- Early-age-onset (age <50 years) breast cancer including both invasive and ductal carcinoma in situ (DCIS) breast cancers
- Two breast primaries or breast and ovarian/fallopian tube/primary peritoneal cancer in a single individual or two or more breast primaries or breast and ovarian/fallopian tube/primary peritoneal cancers in close (first- second- and third-degree) relatives(s) from the same side of the family
- Populations at risk (e.g., Ashkenazi Jewish)
- Member of a family with a known BRCA1 or BRCA2 mutation
- Any male breast cancer
- Ovarian/fallopian tube/primary peritoneal cancer at any age
“It is probably something that women ask about who have this very strong worry that they just want to do everything possible to get it out, including something that might not be necessary to have done,” she said.
She said that among the questions the researchers are exploring is what role the desire for breast reconstruction may have played in patients’ decisions to get a double mastectomy.
“A lot of times it is suggested that it is easier to reconstruct two breasts to be cosmetically similar than one, and so if you are seeing that plastic surgeon as part of your discussion and they mention this, then you may embark on double mastectomy for cosmetic reasons. We weren’t able to look at that yet in our data, but we are able to look at it in some follow-up analysis that we are doing,” she said.
Hawley and her colleagues received a grant from the National Cancer Institute that is helping them develop a decision tool to help guide women through breast cancer treatment choices. This tool will entail an interactive website that will help women go through the key information they need to make decisions about treatment such as double mastectomies.
“If it works the way that we want it to, then some women who come in and are thinking of getting double mastectomy or unilateral mastectomy, they may end up realizing that they could go with something less and still have the same survival benefits,” she said.
VA patient data was not included in Hawley’s research, but Chief of Plastic Surgery at the Bay Pines VA Healthcare System Wyatt Payne, MD, told U.S. Medicine that education is key in helping women, both in the VA and outside of VA, make a decision regarding prophylactic mastectomies.
“One of the best things that physicians, nurses and other providers can do is to try to help allay unfounded fear and to educate our patients as to what the real facts are and to try to help them understand the situation,” he said.
Payne pointed out that, unless a patient is in a high-risk group, the risk of developing breast cancer in the other breast is relatively low. In the VA, like elsewhere, Payne said contralateral prophylactic mastectomies generally would be recommended for consideration only when there is a strong clinical indication.
According to VA, since 2000 the number of female veterans using VA healthcare more than doubled, from nearly 160,000 to more than 337,000 in fiscal year 2011. The agency said in a press release last year that it has outperformed non-VA healthcare systems in breast cancer screenings for more than 15 years, with 87% of eligible women receiving mammograms in the VA healthcare system in fiscal year 2010.
1. Hawley ST, Jagsi R, Katz SJ. Is Contralateral Prophylactic Mastectomy (CPM) Overused? Results from a Population-Based Study, American Society of Clinical Oncology Quality Care Symposium, San Diego, Nov. 30-Dec. 1, 2012.
2. Yao K, Stewart AK, Winchester DJ, et al: Trends in Contralateral Prophylactic Mastectomy for Unilateral Cancer: A Report from the National Cancer Data Base, 1998-2007. Ann Surg. Oncol 17:2554-2562, 2010.