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Singh P, Agnese D, Amin M, Barrio AV, Botty Van den Bruele A, Burke E, Danforth DN, Dirbas FM, Eladoumikdachi F, Kantor O, Kumar S, Lee MC, Matsen C, Nguyen TT, Ozmen T, Park KU, Plichta JK, Reyna C, Showalter SL, Styblo T, Tranakas N, Weiss A, Laronga C, Boughey J. Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks. Ann Surg Oncol 2024; 31:2212-2223. [PMID: 38261126 DOI: 10.1245/s10434-024-14893-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Abstract
Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.
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Affiliation(s)
- Puneet Singh
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | | | - Andrea V Barrio
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | | | - Erin Burke
- University of Kentucky, Lexington, KY, USA
| | | | | | | | - Olga Kantor
- Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Shicha Kumar
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | | | | | - Tolga Ozmen
- Massachusetts General Hospital, Boston, MA, USA
| | - Ko Un Park
- Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Anna Weiss
- University of Rochester Medical Center, Rochester, NY, USA
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Wahlen MM, Lizarraga IM, Kahl AR, Zahnd WE, Eberth JM, Overholser L, Askelson N, Hirschey R, Yeager K, Nash S, Engelbart JM, Charlton ME. Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer. Cancer Causes Control 2023; 34:171-186. [PMID: 37095280 PMCID: PMC10689552 DOI: 10.1007/s10552-023-01689-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/29/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM. METHODS Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options. RESULTS Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30). CONCLUSION The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.
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Affiliation(s)
- Madison M Wahlen
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Ingrid M Lizarraga
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | | | - Whitney E Zahnd
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Jan M Eberth
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
- Department of Health Management and Policy, Drexel University, Philadelphia, PA, USA
| | - Linda Overholser
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Natoshia Askelson
- Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, USA
| | - Rachel Hirschey
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Sarah Nash
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
- Iowa Cancer Registry, Iowa City, IA, USA
| | - Jacklyn M Engelbart
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mary E Charlton
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
- Iowa Cancer Registry, Iowa City, IA, USA
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Zhao B, Yi M, Lyu H, Zhang X, Liu Y, Song X. Decision-making experiences of breast cancer patients related to contralateral prophylactic mastectomy-a systematic meta-synthesis of qualitative studies. Support Care Cancer 2023; 31:214. [PMID: 36918480 DOI: 10.1007/s00520-023-07674-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Currently, the choice of contralateral prophylactic mastectomy (CPM) for breast cancer patients is variable and controversial. Breast cancer patients must make complex and rapid decisions based on the benefits and risks of CPM. Although there are many qualitative studies on the decision-making experiences of breast cancer patients, there is a lack of synthesis of these qualitative studies. Our study goals were to conduct a meta-synthesis of qualitative studies on the decision-making experiences, real-life experiences, psychological feelings and needs of breast cancer patients in CPM decision-making, with the aim of providing information to support the development of CPM practice decisions. METHODS Using a meta-ethnographic approach, qualitative research studies were analysed and synthesised using the method of "reciprocal translational analysis", and themes related to the decision-making experiences of breast cancer patients with respect to CPM were identified. RESULTS Five hundred ninety-three documents were retrieved. This meta-synthesis ultimately collected 8 studies. Four themes were identified: (1) decision motivations for survival and body intention; (2) negative and vacillating decision emotions; (3) diverse but weak decision support; (4) short-term satisfaction but long-term unknown and differentiated decision effects. CONCLUSIONS We found that although patients had different feelings about the effects of CPM in detail, most patients were satisfied with the short-term effects of CPM, but the long-term effects of CPM were still unknown. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in May 2022 (Registration number: CRD42022334260).
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Affiliation(s)
- Baosheng Zhao
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Weiqi Road, Jinan, 250021, Shandong Province, China
| | - Mo Yi
- School of Nursing and Rehabilitation, Shandong University, No. 44 Wenhuaxi Road, Jinan, 250012, Shandong Province, China
| | - Hong Lyu
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Weiqi Road, Jinan, 250021, Shandong Province, China
| | - Xiaoman Zhang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Weiqi Road, Jinan, 250021, Shandong Province, China
| | - Yujie Liu
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Weiqi Road, Jinan, 250021, Shandong Province, China
| | - Xinhong Song
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Weiqi Road, Jinan, 250021, Shandong Province, China.
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Schmidt MK, Kelly JE, Brédart A, Cameron DA, de Boniface J, Easton DF, Offersen BV, Poulakaki F, Rubio IT, Sardanelli F, Schmutzler R, Spanic T, Weigelt B, Rutgers EJT. EBCC-13 manifesto: Balancing pros and cons for contralateral prophylactic mastectomy. Eur J Cancer 2023; 181:79-91. [PMID: 36641897 PMCID: PMC10326619 DOI: 10.1016/j.ejca.2022.11.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/17/2022] [Accepted: 11/26/2022] [Indexed: 12/15/2022]
Abstract
After a diagnosis of unilateral breast cancer, increasing numbers of patients are requesting contralateral prophylactic mastectomy (CPM), the surgical removal of the healthy breast after diagnosis of unilateral breast cancer. It is important for the community of breast cancer specialists to provide meaningful guidance to women considering CPM. This manifesto discusses the issues and challenges of CPM and provides recommendations to improve oncological, surgical, physical and psychological outcomes for women presenting with unilateral breast cancer: (1) Communicate best available risks in manageable timeframes to prioritise actions; better risk stratification and implementation of risk-assessment tools combining family history, genetic and genomic information, and treatment and prognosis of the first breast cancer are required; (2) Reserve CPM for specific situations; in women not at high risk of contralateral breast cancer (CBC), ipsilateral breast-conserving surgery is the recommended option; (3) Encourage patients at low or intermediate risk of CBC to delay decisions on CPM until treatment for the primary cancer is complete, to focus on treating the existing disease first; (4) Provide patients with personalised information about the risk:benefit balance of CPM in manageable timeframes; (5) Ensure patients have an informed understanding of the competing risks for CBC and that there is a realistic plan for the patient; (6) Ensure patients understand the short- and long-term physical effects of CPM; (7) In patients considering CPM, offer psychological and surgical counselling before surgery; anxiety alone is not an indication for CPM; (8) Eliminate inequality between countries in reimbursement strategies; CPM should be reimbursed if it is considered a reasonable option resulting from multidisciplinary tumour board assessment; (9) Treat breast cancer patients at specialist breast units providing the entire patient-centred pathway.
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Affiliation(s)
- Marjanka K Schmidt
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands.
| | | | - Anne Brédart
- Institut Curie, Paris, France; Psychology Institute, Psychopathology and Health Process Laboratory UR4057, Paris City University, Paris, France
| | - David A Cameron
- Edinburgh University Cancer Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St. Göran's Hospital, Stockholm, Sweden
| | - Douglas F Easton
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital - Aarhus University, Aarhus N, Denmark
| | - Fiorita Poulakaki
- Breast Surgery Department, Athens Medical Center, Athens, Greece; Europa Donna - The European Breast Cancer Coalition, Milan, Italy
| | - Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy; Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Rita Schmutzler
- Center for Hereditary Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), University Hospital Cologne, Cologne, Germany
| | - Tanja Spanic
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy; Europa Donna Slovenia, Ljubljana, Slovenia
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emiel J T Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Rooney MM, Thomas SM, Taskindoust M, Greenup RA, Rosenberger LH, Hwang ES, Plichta JK. The role of tumor phenotype in the surgical treatment of early-stage breast cancer. Am J Surg 2023; 225:84-92. [PMID: 36180300 PMCID: PMC9912362 DOI: 10.1016/j.amjsurg.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/10/2022] [Accepted: 09/18/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND We investigated whether tumor phenotype influences surgical decision-making, and how that may impact overall survival (OS) for early-stage breast cancer. METHODS Women aged 18-69 with cT0-2/cN0/cM0 breast cancer in the National Cancer Database (2010-2017) were included. A generalized logistic model was used to identify factors associated with surgery type. A Kaplan-Meier curve was used to visualize unadjusted OS, and the log-rank test was used to test for differences in OS between surgery types. RESULTS Of 597,149 patients, 58% underwent lumpectomy with radiation (BCT), 25% unilateral mastectomy (UM), and 17% bilateral mastectomy (BM). After adjustment, HER2+ and triple-negative (TN) tumors were less likely to undergo UM than BCT, versus hormone receptor-positive tumors (OR = 0.881, 95% CI = 0.860-0.903; OR = 0.485, 95% CI = 0.470-0.501). UM and BM had worse 5-year OS versus BCT (UM: 0.926, vs BM: 0.952, vs BCT: 0.960). CONCLUSIONS BCT is increasingly used to treat HER2+ and TN tumors. More extensive surgery is not associated with better survival outcomes, regardless of tumor phenotype.
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Affiliation(s)
| | - Samantha M Thomas
- Duke Cancer Institute, Durham, NC, USA; Duke University, Department of Biostatistics & Bioinformatics, Durham, NC, USA
| | | | | | - Laura H Rosenberger
- Duke Cancer Institute, Durham, NC, USA; Duke University Medical Center, Department of Surgery, Durham, NC, USA
| | - E Shelley Hwang
- Duke Cancer Institute, Durham, NC, USA; Duke University Medical Center, Department of Surgery, Durham, NC, USA
| | - Jennifer K Plichta
- Duke Cancer Institute, Durham, NC, USA; Duke University Medical Center, Department of Surgery, Durham, NC, USA; Duke University Medical Center, Department of Population Health Sciences, New Haven, NC, USA.
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Greenfield G, Shmueli L, Harvey A, Quezada-Yamamoto H, Davidovitch N, Pliskin JS, Rawaf S, Majeed A, Hayhoe B. Patient-initiated second medical consultations-patient characteristics and motivating factors, impact on care and satisfaction: a systematic review. BMJ Open 2021; 11:e044033. [PMID: 34561250 PMCID: PMC8475134 DOI: 10.1136/bmjopen-2020-044033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction and cost effectiveness. DATA SOURCES Embase, Medline, PsycINFO and Health Management Information Consortium (HMIC) databases. STUDY DESIGN A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. DATA COLLECTION/EXTRACTION METHODS We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions. PRINCIPAL FINDINGS Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions. CONCLUSIONS This review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.
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Affiliation(s)
- Geva Greenfield
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Liora Shmueli
- Department of Management, Bar-Ilan University, Ramat-Gan, Israel
| | - Amy Harvey
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Harumi Quezada-Yamamoto
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Nadav Davidovitch
- Health Policy and Management, School of Public Health, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Joseph S Pliskin
- Health Policy and Management, School of Public Health, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Salman Rawaf
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Azeem Majeed
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Benedict Hayhoe
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
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Wallner LP, Banerjee M, Reyes-Gastelum D, Hamilton AS, Ward KC, Lubitz C, Hawley ST, Haymart MR. Multilevel Factors Associated With More Intensive Use of Radioactive Iodine for Low-Risk Thyroid Cancer. J Clin Endocrinol Metab 2021; 106:e2402-e2412. [PMID: 33687063 PMCID: PMC8118575 DOI: 10.1210/clinem/dgab139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Indexed: 12/28/2022]
Abstract
CONTEXT The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs. OBJECTIVE To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer. METHODS This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer. RESULTS Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67). CONCLUSIONS Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.
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Affiliation(s)
- Lauren P Wallner
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
| | | | - Ann S Hamilton
- Keck School of Medicine, University of Southern California, Department of Preventive Medicine, Los Angeles, CA, USA
| | - Kevin C Ward
- Emory University, Department of Epidemiology, Atlanta, GA, USA
| | - Carrie Lubitz
- Massachusetts General Hospital, Department of Surgery, Boston, MA, USA
| | - Sarah T Hawley
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Departments of Health Management and Policy and Health Behavior and Education, Ann Arbor, MI, USA
| | - Megan R Haymart
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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8
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Lim DW, Metcalfe KA, Narod SA. Bilateral Mastectomy in Women With Unilateral Breast Cancer: A Review. JAMA Surg 2021; 156:569-576. [PMID: 33566074 DOI: 10.1001/jamasurg.2020.6664] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Rates of bilateral mastectomy continue to increase in average-risk women with unilateral in situ and invasive breast cancer. Contralateral prophylactic mastectomy rates increased from 5% to 12% of all operations for breast cancer in the US from 2004 to 2012. Among women having mastectomy, rates of contralateral prophylactic mastectomy have increased from less than 2% in 1998 to 30% in 2012. Observations The increased use of breast magnetic resonance imaging and genetic testing has marginally increased the number of candidates for bilateral mastectomy. Most bilateral mastectomies are performed on women who are at no special risk for contralateral cancer. The true risk of contralateral breast cancer is not associated with the decision for contralateral prophylactic mastectomy; rather, the clinical factors associated with the probability of distant recurrence are associated with bilateral mastectomy. Several changes in society and health care delivery appear to act concurrently and synergistically. First, the anxiety engendered by a fear of cancer recurrence is focused on the contralateral cancer because this is most easily conceptualized and provides a ready target that can be acted upon. Second, the modern woman with breast cancer is supported by the surgeon and the social community of breast cancer survivors. Surgeons want to respect patient autonomy, despite guidelines discouraging bilateral mastectomy, and most women have their expenses covered by a third-party payer. Satisfaction with the results is high, but the association with improved psychosocial well-being remains to be fully understood. Conclusions and Relevance Reducing the use of medically unnecessary contralateral prophylactic mastectomy in women with nonhereditary, unilateral breast cancer requires a social change that addresses patient-, physician-, cultural-, and systems-level enabling factors. Such a transformation begins with educating clinicians and patients. The concerns of women who want preventive contralateral mastectomy must be explored, and women need to be informed of the anticipated benefits (or lack thereof) and risks. Areas requiring further study are considered.
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Affiliation(s)
- David W Lim
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Kelly A Metcalfe
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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9
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Scheepens JCC, Veer LV', Esserman L, Belkora J, Mukhtar RA. Contralateral prophylactic mastectomy: A narrative review of the evidence and acceptability. Breast 2021; 56:61-69. [PMID: 33621798 PMCID: PMC7907889 DOI: 10.1016/j.breast.2021.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/29/2021] [Accepted: 02/06/2021] [Indexed: 12/26/2022] Open
Abstract
The uptake of contralateral prophylactic mastectomy (CPM) has increased steadily over the last twenty years in women of all age groups and breast cancer stages. Since contralateral breast cancer is relatively rare and the breast cancer guidelines only recommend CPM in a small subset of patients with breast cancer, the drivers of this trend are unknown. This review aims to evaluate the evidence for and acceptability of CPM, data on patient rationales for choosing CPM, and some of the factors that might impact patient preferences. Based on the evidence, future recommendations will be provided. First, data on contralateral breast cancer risk and CPM rates and trends are addressed. After that, the evidence is structured around four main patient rationales for CPM formulated as questions that patients might ask their surgeon: Will CPM reduce mortality risk? Will CPM reduce the risk of contralateral breast cancer? Can I avoid future screening with CPM? Will I have better breast symmetry after CPM? Also, three different guidelines regarding CPM will be reviewed. Studies indicate a large gap between patient preferences for radical risk reduction with CPM and the current approaches recommended by important guidelines. We suggest a strategy including shared decision-making to enhance surgeons’ communication with patients about contralateral breast cancer and treatment options, to empower patients in order to optimize the use of CPM incorporating accurate risk assessment and individual patient preferences. Contralateral prophylactic mastectomy rates have increased over the last 20 years. Patients may want CPM to reduce risk of contralateral breast cancer and mortality. Patients do not always have the tools available to make a well-informed decision. Patient and surgeon’s shared decision-making could optimize the use of CPM.
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Affiliation(s)
- Josien C C Scheepens
- University of California, San Francisco, Department of Laboratory Medicine, 2340 Sutter St., Box 0808, San Francisco, CA, 94115, USA
| | - Laura van 't Veer
- University of California, San Francisco, Department of Laboratory Medicine, 2340 Sutter St., Box 0808, San Francisco, CA, 94115, USA
| | - Laura Esserman
- University of California, San Francisco, Department of Surgery, 1825 4th Street, 3rd Floor, Box 1710, San Francisco, CA, 94143-1710, USA
| | - Jeff Belkora
- University of California, San Francisco, Institute for Health Policy Studies and Department of Surgery, 3333 California Street, Suite 265, San Francisco, CA, 94118, USA
| | - Rita A Mukhtar
- University of California, San Francisco, Department of Surgery, 1825 4th Street, 3rd Floor, Box 1710, San Francisco, CA, 94143-1710, USA.
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Laterality and Patient-Reported Outcomes following Autologous Breast Reconstruction with Free Abdominal Tissue: An 8-Year Examination of BREAST-Q Data. Plast Reconstr Surg 2020; 146:964-975. [PMID: 33141527 DOI: 10.1097/prs.0000000000007239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making. METHODS The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years. RESULTS Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively). CONCLUSIONS These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.
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11
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Thompson R, Muscat DM, Jansen J, Cox D, Zadro JR, Traeger AC, McCaffery K. Promise and perils of patient decision aids for reducing low-value care. BMJ Qual Saf 2020; 30:bmjqs-2020-012312. [PMID: 33361344 DOI: 10.1136/bmjqs-2020-012312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/26/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Rachel Thompson
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Danielle M Muscat
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Darlene Cox
- Health Care Consumers' Association, Hackett, Australian Capital Territory, Australia
| | - Joshua R Zadro
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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12
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Canada follows the US in the rise of bilateral mastectomies for unilateral breast cancer: a 23-year population cohort study. Breast Cancer Res Treat 2020; 185:517-525. [PMID: 33128192 DOI: 10.1007/s10549-020-05965-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The use of contralateral prophylactic mastectomy (CPM) continues to grow despite the absence of evidence supporting a survival benefit. This study's objectives were to (1) describe the trends in the rates of unilateral and bilateral mastectomy (BM) in women diagnosed with unilateral breast cancer (UBC) in Ontario, Canada from 1991 to 2013, and (2) identify factors associated with BM to treat UBC. METHODS This retrospective cohort analysis included all women aged 18 and older diagnosed with UBC between January 1991 and December 2013. Health administrative data from the Institute for Clinical Evaluative Sciences, the Ontario Cancer Registry, and the Discharge Abstract Database were used to identify all breast cancer and mastectomy cases. Age-adjusted mastectomy rates were plotted over time. Univariable and multivariable analyses included clinically significant covariates. RESULTS From 1991 to 2013 there were 172,165 cases of UBC and 64,886 mastectomies (37.7%) performed in Ontario. 13.6% of the mastectomies were bilateral. BM rates increased over sixfold (from 4 to 25%) across all age groups under age 70 over a 23-year period. On multivariable analysis, younger age, higher income, rural community, earlier breast cancer stage, lobular histology, availability of reconstruction and teaching hospitals were associated with increased odds of BM. CONCLUSIONS This is the largest population study of breast cancer patients in Canada and shows an increasing rate of BM for UBC. The results are similar to those already described in the US and highlight the importance of continued efforts to promote efficient communication and evidence-based decision-making prior to breast surgery.
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13
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Bekeny JC, Schreeder CA, Wirth P, Luvisa K, Perez‐Alvarez IM, Black CK, Giladi A, Song DH, Willey SC, Fan KL. Factors contributing to persistent rates of contralateral prophylactic mastectomy in breast cancer patients: Examination of 1051 mastectomies across a single health system. Breast J 2020; 26:2341-2349. [DOI: 10.1111/tbj.14080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Jenna C. Bekeny
- Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Caroline A. Schreeder
- Department of General Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Peter Wirth
- Georgetown University School of Medicine Washington DC USA
| | - Kyle Luvisa
- Georgetown University School of Medicine Washington DC USA
| | | | - Cara K. Black
- Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Aviram Giladi
- Department of Plastic and Reconstructive Surgery MedStar Union Memorial Hospital Baltimore, MD USA
| | - David H. Song
- Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Shawna C. Willey
- Inova Schar Cancer InstituteInova Fairfax Hospital Fairfax VA USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington DC USA
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14
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Minami CA, King TA, Mittendorf EA. Patient preferences for locoregional therapy in early-stage breast cancer. Breast Cancer Res Treat 2020; 183:291-309. [DOI: 10.1007/s10549-020-05737-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
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15
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D’Agostino TA, Brewster AM, Peterson SK, Bedrosian I, Parker PA. Discussions about contralateral prophylactic mastectomy among surgical oncology providers and women with sporadic breast cancer: a content analysis. Transl Behav Med 2020; 10:347-354. [PMID: 30561744 PMCID: PMC7237543 DOI: 10.1093/tbm/iby098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Rates of contralateral prophylactic mastectomy (CPM) have risen substantially, yet little is known about how and to what extent CPM is discussed within surgical oncology visits at the time of treatment decision-making. We examined CPM discussions in naturally occurring interactions between sporadic breast cancer patients and their surgical oncology providers. Women with early-stage unilateral disease were recruited before their first surgical visit and completed brief questionnaires to determine study eligibility and interest in treatment options. After their visits, enrolled patients and their providers completed questionnaires assessing discussion of and interest in CPM. Audio-recorded visits from 36 unique patients were randomly selected, transcribed, and analyzed. A CPM discussion was present in 28 transcripts. Approximately half of CPM discussions were initiated by the patient or the oncology provider. The topic of CPM was most frequently introduced while reviewing available treatment options. Patients were most interested in pursuing CPM to reduce the risk of future breast cancer. Providers most frequently responded by offering information (e.g., about risk of contralateral disease). A high level of agreement was found among patient, provider, and observer ratings of whether or not CPM was discussed. CPM discussions were consistently present within our sample. Results can be used to build providers' skills and bring provider-patient communication more in line with best practices and recommendations from leading professional medical societies.
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Affiliation(s)
- Thomas A D’Agostino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Albany Stratton VA Medical Center, Albany, NY, USA
| | - Abenaa M Brewster
- Department of Clinical Cancer Prevention, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K Peterson
- Department of Behavioral Science, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patricia A Parker
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Thorneloe RJ, Hall LH, Walter FM, Side L, Lloyd KE, Smith SG. Knowledge of Potential Harms and Benefits of Tamoxifen among Women Considering Breast Cancer Preventive Therapy. Cancer Prev Res (Phila) 2020; 13:411-422. [PMID: 31988145 PMCID: PMC7611305 DOI: 10.1158/1940-6207.capr-19-0424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/19/2019] [Accepted: 01/21/2020] [Indexed: 12/28/2022]
Abstract
Tamoxifen reduces breast cancer incidence in women at increased risk, but may cause side effects. We examined women's knowledge of tamoxifen's potential harms and benefits, and the extent to which knowledge reflects subjective judgments of awareness and decision quality. After a hospital appointment, 408 (55.7%) women at increased risk of breast cancer completed a survey assessing objective knowledge about the potential benefit (risk reduction) and harms (endometrial cancer, thromboembolic events, and menopausal side effects) of tamoxifen, and subjective tamoxifen knowledge and decisional quality. Two hundred fifty-eight (63.2%) completed a 3-month follow-up survey. Sixteen percent (15.7%) of participants recognized the potential benefit and three major harms of using tamoxifen. These women were more likely to have degree-level education [vs. below degree level; OR, 2.24; 95% confidence interval (CI), 1.11-4.55] and good numeracy (vs. poor numeracy; OR, 5.91; 95% CI, 1.33-26.19). Tamoxifen uptake was higher in women who recognized all harms and benefits (vs. not recognizing; OR, 2.47; 95% CI, 0.94-6.54). Sixty-six percent (65.8%) of tamoxifen users were unaware of its potential benefit and harms. Most (87.1%) women reported feeling informed about tamoxifen, and subjective decisional quality was high [Mean (SD), 17.03 (1.87), out of 18]. Knowledge regarding the potential harms and benefit of tamoxifen is low in women considering prevention therapy, and they may need additional support to make informed decisions about tamoxifen preventive therapy.
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Affiliation(s)
| | - Louise Hazel Hall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Fiona Mary Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Lucy Side
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, United Kingdom
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17
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Montagna G, Morrow M. Contralateral prophylactic mastectomy in breast cancer: what to discuss with patients. Expert Rev Anticancer Ther 2020; 20:159-166. [PMID: 32077338 DOI: 10.1080/14737140.2020.1732213] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: The contralateral prophylactic mastectomy (CPM) rate in the U.S. has been steadily increasing. This is of particular concern because many women who undergo this procedure are candidates for breast-conserving surgery.Areas covered: CPM's medical benefit is related to the risk of contralateral cancer development and whether CPM provides a survival benefit. Contralateral cancer rates have decreased, and CPM does not provide a survival benefit. Other potential benefits of the procedure may be improved quality of life; these data are reviewed. Research efforts have been undertaken to better understand the decision-making process of patients who consider, and ultimately undergo, this procedure.Expert opinion: Decisional traits, personal values, the desire for peace of mind, and the desire to obtain breast symmetry are important factors that drive a woman's decision to undergo CPM. Additionally, many patients lack the knowledge on how different types of breast surgery impact outcomes. To improve the shared decision-making process, a stepwise approach to address possible misconceptions, and clarify the real risks/benefits of this procedure should be utilized. A clear recommendation (for/against) should be made for every patient with newly diagnosed breast cancer who considers CPM. Communication tools to assist patients and surgeons in this process are sorely needed.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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18
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Terkelsen T, Rønning H, Skytte AB. Impact of genetic counseling on the uptake of contralateral prophylactic mastectomy among younger women with breast cancer. Acta Oncol 2020; 59:60-65. [PMID: 31379231 DOI: 10.1080/0284186x.2019.1648860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Preoperative genetic testing affects the surgical decision-making among women with breast cancer. To avoid breast-conserving surgery and to offer the possibility of mastectomy with immediate reconstruction in high-risk patients, genetic testing for pathogenic variants in BRCA1 or BRCA2 and a pedigree-based familial breast cancer risk assessment was offered to younger women with breast cancer in Denmark. We evaluated the impact of the risk stratification through genetic counseling on the uptake of contralateral prophylactic mastectomy (CPM).Material and methods: The prospective cohort study included all women with unilateral breast cancer before the age of 45 who participated in a genetic counseling program during their primary diagnostics in the Central Denmark Region (2013-2018). Each patient was followed from the time of the genetic test result to the end of follow-up to estimate the long-term uptake of CPM as a competing risk-adjusted cumulative incidence. We compared the uptake of CPM between the various genetic risk categories, ages of onset, and family histories in a multivariable Cox proportional hazards regression model, reporting hazard ratios (HR) with two-sided 95% confidence intervals (CIs).Results: 156 females, aged 21-44, learned their genetic test result within a median of 92 days [interquartile range (IQR): 75-114]. The maximal follow-up was 3.8 years (median 1.8; IQR: 0.49-2.5), after which 33% (95% CI: 24-42%) of the patients had undergone CPM. The uptake of CPM was inversely associated with the age of onset (HR 0.92; 95% CI: 0.86-0.98) and significantly higher among BRCA carriers (HR 2.9; 95% CI: 1.3-6.8) and patients from the high risk of breast cancer families (HR 5.6; 95% CI: 1.9-16) compared to the lower genetic risk categories.Conclusion: The risk stratification obtained through genetic counseling had a considerable impact on the surgical decision-making among younger women with breast cancer at long-term follow-up.
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Affiliation(s)
- Thorkild Terkelsen
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - Hanne Rønning
- Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Bine Skytte
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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19
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Yao K, Belkora J, Lee C, Kuchta K, Pesce C, Kopkash K, Rabbitt S, Barrera E, Simovic S, Sepucha K. An In-Visit Decision Aid for Surgeons to Address Decision Making for Bilateral Mastectomy for Newly Diagnosed Breast Cancer Patients. Ann Surg Oncol 2019; 26:4372-4380. [DOI: 10.1245/s10434-019-07912-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 11/18/2022]
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20
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Katz SJ, Bondarenko I, Ward KC, Hamilton AS, Morrow M, Kurian AW, Hofer TP. Association of Attending Surgeon With Variation in the Receipt of Genetic Testing After Diagnosis of Breast Cancer. JAMA Surg 2019; 153:909-916. [PMID: 29971344 DOI: 10.1001/jamasurg.2018.2001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Genetic testing after diagnosis of breast cancer is common, but little is known about the influence of the surgeon on the variation in testing. Objectives To quantify and explain the association of attending surgeon with rates of genetic testing after diagnosis of breast cancer. Design, Setting, and Participants This population-based study identified 7810 women with stages 0 to II breast cancer treated between July 1, 2013, and August 31, 2015, through the Surveillance, Epidemiology, and End Results registries for the state of Georgia, as well as Los Angeles County, California. Surveys were sent approximately 2 months after surgery. Also surveyed were 488 attending surgeons identified by the patients. Main Outcomes and Measures The study examined the association of surgeon with variation in the receipt of genetic testing using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results and genetic testing data obtained from 4 laboratories. Results In total, 5080 women (69.6%) of 7303 who were eligible (mean [SD] age, 61.4 [0.8] years) and 377 surgeons (77.3%) of 488 (mean [SD] age, 53.8 [10.7] years) responded to the survey. Approximately one-third (34.5% [1350 of 3910] of patients had an elevated risk of mutation carriage, and 27.0% (1056 of 3910) overall had genetic testing. Surgeons had practiced a mean (SE) of 20.9 (0.6) years, and 28.9% (107 of 370) treated more than 50 cases of new breast cancer per year. The odds of a patient receiving genetic testing increased more than 2-fold (odds ratio, 2.48; 95% CI, 1.85-3.31) if she saw a surgeon with an approach 1 SD above that of a surgeon with the mean test rate. Approximately one-third (34.1%) of the surgeon variation was explained by patient volume and surgeon attitudes about genetic testing and counseling. If a patient with higher pretest risk saw a surgeon at the 5th percentile of the surgeon distribution, she would have a 26.3% (95% CI, 21.9%-31.2%) probability of testing compared with 72.3% (95% CI, 66.7%-77.2%) if she saw a surgeon at the 95th percentile. Conclusions and Relevance In this study, the attending surgeon was associated with the receipt of genetic testing after a breast cancer diagnosis. Variation in surgeon attitudes about genetic testing and counseling may explain a substantial amount of this association.
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Affiliation(s)
- Steven J Katz
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Irina Bondarenko
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Kevin C Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Keck School of Medicine, University of Southern California, Los Angeles
| | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Allison W Kurian
- Department of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University, Stanford, California
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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21
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Wallner LP, Reyes-Gastelum D, Hamilton AS, Ward KC, Hawley ST, Haymart MR. Patient-Perceived Lack of Choice in Receipt of Radioactive Iodine for Treatment of Differentiated Thyroid Cancer. J Clin Oncol 2019; 37:2152-2161. [PMID: 31283406 PMCID: PMC6698919 DOI: 10.1200/jco.18.02228] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE For many patients with differentiated thyroid cancer, use of radioactive iodine (RAI) does not improve survival or reduce recurrence risk. Yet there is wide variation in RAI use, emphasizing the importance of understanding patient perspectives regarding RAI decision making. PATIENTS AND METHODS All eligible patients diagnosed with thyroid cancer from 2014 to 2015 from the Georgia and Los Angeles SEER registries were surveyed (N = 2,632; response rate, 63%). Patients in whom selective RAI use is recommended were included in this analysis (n = 1,319). Patients were asked whether they felt like they had a choice to receive RAI (yes or no), how strongly their physician recommended RAI (5-point Likert-type scale), whether they received RAI (yes or no), and how satisfied they were with their RAI decision (more [score of 4 or greater] v less). Multivariable, weighted logistic regression with multiple imputation was used to assess the associations between patient characteristics and perception of no RAI choice and between perception of no RAI choice with receipt of RAI and decision satisfaction. RESULTS More than half of respondents (55.8%) perceived they did not have an RAI choice, and the majority of patients (75.9%) received RAI. The odds of perceiving no RAI choice was greater among those whose physician strongly recommended RAI (adjusted odds ratio [OR], 1.56; 95% CI, 1.13 to 2.17). Patients who perceived they did not have an RAI choice were more likely to receive RAI (adjusted OR, 2.50; 95% CI, 1.64 to 3.82) and report lower decision satisfaction (adjusted OR, 2.31; 95% CI, 1.67 to 3.20). CONCLUSION Many patients did not feel they had a choice about whether to receive RAI. Patients who perceived they did not have a choice were more likely to receive RAI and report lower decision satisfaction, suggesting a need for more shared decision making to reduce overtreatment.
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Affiliation(s)
| | | | - Ann S. Hamilton
- University of Southern California Keck School of Medicine, Los Angeles, CA
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22
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Squires JE, Simard SN, Asad S, Stacey D, Graham ID, Coughlin M, Clemons M, Grimshaw JM, Zhang J, Caudrelier JM, Arnaout A. Exploring reasons for overuse of contralateral prophylactic mastectomy in Canada. ACTA ACUST UNITED AC 2019; 26:e439-e457. [PMID: 31548812 DOI: 10.3747/co.26.4951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca. Methods This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs. Results In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%). Conclusions Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.
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Affiliation(s)
- J E Squires
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON
| | - S N Simard
- Bloomberg School of Nursing, University of Toronto, Toronto, ON
| | - S Asad
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON
| | - D Stacey
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON
| | - I D Graham
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON
| | - M Coughlin
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON
| | - M Clemons
- Department of Medicine, University of Ottawa, Ottawa, ON.,Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON.,Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, ON
| | - J M Grimshaw
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON.,Department of Medicine, University of Ottawa, Ottawa, ON
| | - J Zhang
- Department of Plastic Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON
| | - J M Caudrelier
- Department of Radiation Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, ON
| | - A Arnaout
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, ON.,Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON
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Taylor MA, Allen CM, Presson AP, Millar MM, Zurbuchen R, Matsen CB. Exploring Surgeon Variability in Recommendations for Contralateral Prophylactic Mastectomy: What Matters Most? Ann Surg Oncol 2019; 26:3224-3231. [DOI: 10.1245/s10434-019-07561-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Indexed: 12/20/2022]
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24
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Huang J, Chagpar A. Active Participation in Decision-Making in Contralateral Prophylactic Mastectomy for Patients With Breast Cancer. J Surg Res 2019; 242:129-135. [PMID: 31075657 DOI: 10.1016/j.jss.2019.04.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/01/2019] [Accepted: 04/09/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND We sought to determine how patient-physician communication affects patients' decision-making when choosing between contralateral prophylactic mastectomy (CPM) and unilateral mastectomy (UM). METHODS atients with breast cancer who underwent mastectomy at our institution were approached with a survey regarding patient-physician communication in CPM. RESULTS Of 101 patients who completed the survey, 55 underwent CPM (54.5%). Thirty-three patients (33%) stated that their physician recommended UM, six (6%) stated their physician recommended CPM, and 61 (61%) stated they engaged in active participation in decision-making. Most patients whose doctors recommended UM chose UM (78.8%); similarly, 83.3% of those whose doctors recommended CPM chose CPM. Of 39 patients whose doctors recommended a particular surgical option, eight (20.5%) did not follow their doctor's advice. These patients were equally as satisfied with their decisions as those who followed their doctor's advice (P = 0.441). Patients engaging in active participation in decision-making tended to choose CPM (68.3% versus 30.8%, P < 0.001). Patients who did not engage in active participation were similarly satisfied with their decision as those who did (P = 0.286). Twelve patients (12%) stated they preferred their doctor to provide a recommendation, seven (7%) preferred to make the decision on their own, and 81 (81%) preferred to actively participate in their decision-making with the physician. CONCLUSIONS Patients tend to follow physicians' recommendation of UM or CPM; patients engaging in SDM tend to choose CPM. Most patients prefer to engage in active participation in decision-making with their physician but were equally satisfied with their surgical decision whether they engaged in active participation or not.
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Affiliation(s)
- Julian Huang
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Anees Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
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Squires JE, Stacey D, Coughlin M, Greenough M, Roberts A, Dorrance K, Clemons M, Caudrelier JM, Graham ID, Zhang J, Varin MD, Arnaout A. Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study. Curr Oncol 2019; 26:137-148. [PMID: 31043816 PMCID: PMC6476460 DOI: 10.3747/co.26.4689] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm. Methods A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions. Results The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da. Conclusions The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.
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Affiliation(s)
- J E Squires
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - D Stacey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - M Coughlin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - M Greenough
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - A Roberts
- Breast Surgical Oncology Unit, The Ottawa Hospital, Ottawa, ON
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - K Dorrance
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - M Clemons
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Medicine, University of Ottawa, Ottawa, ON
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, ON
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
| | - J M Caudrelier
- Department of Radiation Medicine, The Ottawa Hospital, Ottawa, ON
| | - I D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON
| | - J Zhang
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, ON
- Department of Plastic Surgery, The Ottawa Hospital, Ottawa, ON
| | - M Demery Varin
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON
| | - A Arnaout
- Breast Surgical Oncology Unit, The Ottawa Hospital, Ottawa, ON
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, ON
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Myers PL, Park RH, Mitchell DC, Nghiem BT, Amalfi AN. Would Plastic Surgeons Choose Breast Conservation Therapy? Ann Plast Surg 2019; 82:S202-S207. [PMID: 30855389 DOI: 10.1097/sap.0000000000001922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Breast conservation therapy is defined as partial mastectomy with subsequent radiation therapy and is the treatment for early-stage breast cancer. However, the unwanted risks of radiation must be considered as well as the impact on future breast reconstruction options. The purpose of this study was to assess the preference of plastic surgeons when given the hypothetical diagnosis of breast cancer. METHODS A survey assessing treatment preference of 3 hypothetical breast cancer diagnosis scenarios was designed and distributed by American Society of Plastic Surgeons via e-mail invite to its members. RESULTS The risk of cancer recurrence was the most common reason for treatment preferences of all three choices. However, for ductal carcinoma in situ, unilateral mastectomy with implant-based reconstruction is the preferred option with the second most influential reason of avoiding the risks of radiation therapy. For invasive ductal carcinoma node negative, unilateral mastectomy with implant-based reconstruction was the preferred option also due to risks of radiation therapy and anxiety of future surveillance. For invasive ductal carcinoma node positive, bilateral mastectomy with implant-based reconstruction was the preferred choice because of anxiety of future surveillance and also risks of radiation therapy. CONCLUSIONS In general, plastic surgeons did not prefer breast conservation therapy for in situ and early-stage breast cancer. Although the most common rationale for total mastectomy was risk of cancer recurrence for all disease severity, risks of radiation therapy are real and play an integral role in the decision-making process. In understanding our own biases, we can help better empathize with patients in consultation for breast reconstruction.
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Affiliation(s)
| | - Rachel H Park
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Drew C Mitchell
- University of Rochester School of Medicine and Dentistry, Rochester, NY
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Huesch MD, Schetter SE, Chetlen AL. Contralateral prophylactic mastectomy and patient mentions on Facebook. Breast J 2018; 24:1123-1125. [PMID: 30036903 DOI: 10.1111/tbj.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 07/26/2017] [Accepted: 02/28/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Marco D Huesch
- Department of Radiology, Milton S. Hershey Medical Center and Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Susann E Schetter
- Department of Radiology, Milton S. Hershey Medical Center and Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Alison L Chetlen
- Department of Radiology, Milton S. Hershey Medical Center and Pennsylvania State University College of Medicine, Hershey, Pennsylvania
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28
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Ager B, Jansen J, Porter D, Phillips KA, Glassey R, Butow P. Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy. Breast 2018; 40:156-164. [PMID: 29857282 DOI: 10.1016/j.breast.2018.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/23/2018] [Accepted: 05/18/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Describe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM). METHODS The DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a 'think aloud approach'. Framework analysis was used to code and analyse data. RESULTS Twenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options. CONCLUSION The DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options. PRACTICE IMPLICATIONS Women appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.
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Affiliation(s)
- B Ager
- School of Psychology, The University of Sydney, Australia
| | - J Jansen
- Sydney Medical School, The University of Sydney, Australia; Psycho-Oncology Co-Operative Research Group (PoCoG), The University of Sydney, Australia
| | - D Porter
- Department of Medical Oncology, Auckland Hospital, Auckland, New Zealand; Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
| | - K A Phillips
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - R Glassey
- Medical School, The University of Western Australia, Perth, Australia
| | | | - P Butow
- Psycho-Oncology Co-Operative Research Group (PoCoG), The University of Sydney, Australia; Centre for Medical Psychology and Evidence Based Decision-Making, The University of Sydney, Australia.
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Rosenberg SM, Greaney ML, Patenaude AF, Sepucha KR, Meyer ME, Partridge AH. "I don't want to take chances.": A qualitative exploration of surgical decision making in young breast cancer survivors. Psychooncology 2018; 27:1524-1529. [PMID: 29476578 DOI: 10.1002/pon.4683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 02/01/2018] [Accepted: 02/14/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Young women with unilateral breast cancer are increasingly choosing contralateral prophylactic mastectomy (CPM), despite its limited medical benefit for most women. The purpose of this study was to better understand this choice through a qualitative exploration of surgical decision-making in young survivors, including how issues particular to younger women affected their decision and the post-surgical experience. METHODS Women age ≤ 40 years with stage 0 to III breast cancer, 1 to 3 years from diagnosis who had undergone breast cancer surgery were recruited to participate. Four focus groups were conducted: 2 with women who had bilateral mastectomy and 2 with women who kept their contralateral breast. Focus groups were recorded and transcribed with identifiers removed. Emergent themes were identified by thematic content analysis using NVivo 11. RESULTS Of the 20 participants, median age at diagnosis was 37 years. Emergent themes were categorized into the following domains: (1) emotions/feelings surrounding surgery/decision about surgery; (2) factors affecting the decision; (3) communication and interaction with the healthcare team; (4) impact on post-surgical life and recovery; and (5) support needs. Young women who chose CPM often were concerned about a future breast event, despite this low risk, suggesting some gain peace of mind by choosing CPM. Young survivors also had many physical and emotional concerns after surgery for which they did not always feel prepared. CONCLUSIONS Informational resources and decision aids may enhance patient-doctor communication and help young survivors better understand risk and manage expectations surrounding short and longer-term physical and emotional effects after surgery.
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Katz SJ, Hawley ST, Hamilton AS, Ward KC, Morrow M, Jagsi R, Hofer TP. Surgeon Influence on Variation in Receipt of Contralateral Prophylactic Mastectomy for Women With Breast Cancer. JAMA Surg 2018; 153:29-36. [PMID: 28903158 PMCID: PMC5833615 DOI: 10.1001/jamasurg.2017.3415] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/14/2017] [Indexed: 11/14/2022]
Abstract
Importance Rates of contralateral prophylactic mastectomy (CPM) have markedly increased but we know little about the influence of surgeons on variability of the procedure in the community. Objective To quantify the influence of the attending surgeon on rates of CPM and clinician attitudes that explained it. Design, Setting, and Participants In this population-based survey study, we identified 7810 women with stages 0 to II breast cancer treated in 2013 to 2015 through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery. Surveys were also sent to 488 attending surgeons identified by the patients. Main Outcomes and Measures We conducted multilevel analyses to examine the impact of surgeon influence on variations in patient receipt of CPM using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results data. Results A total of 5080 women responded to the survey (70% response rate), and 377 surgeons responded (77% response rate). The mean (SD) age of responding women was 61.9 (11) years; 28% had an increased risk of second primary cancer, and 16% received CPM. Half of surgeons (52%) practiced for more than 20 years and 30% treated more than 50 new patients with breast cancer annually. Attending surgeon explained a large amount (20%) of the variation in CPM, controlling for patient factors. The odds of a patient receiving CPM increased almost 3-fold (odds ratio, 2.8; 95% CI, 2.1-3.4) if she saw a surgeon with a practice approach 1 SD above a surgeon with the mean CPM rate (independent of age, diagnosis date, BRCA status, and risk of second primary). One-quarter (25%) of the surgeon influence was explained by attending attitudes about initial recommendations for surgery and responses to patient requests for CPM. The estimated rate of CPM was 34% for surgeons who least favored initial breast conservation and were least reluctant to perform CPM vs 4% for surgeons who most favored initial breast conservation and were most reluctant to perform CPM. Conclusions and Relevance In this study, attending surgeons exerted influence on the likelihood of receipt of CPM after a breast cancer diagnosis. Variations in surgeon attitudes about recommendations for surgery and response to patient requests for CPM explain a substantial amount of this influence.
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Affiliation(s)
- Steven J. Katz
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Sarah T. Hawley
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Veterans Administration Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan
| | - Ann S. Hamilton
- Keck School of Medicine, University of Southern California, Los Angeles
| | - Kevin C. Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Monica Morrow
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor
| | - Timothy P. Hofer
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Service Center of Innovation and Department of Internal Medicine, University of Michigan, Ann Arbor
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