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Waters EA, Pachur T, Pogge G, Hunleth J, Webster GD, Shepperd JA. Linking cognitive and affective heuristic cues to interpersonal risk perceptions and behavior. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2023; 43:2610-2630. [PMID: 36781299 PMCID: PMC10423305 DOI: 10.1111/risa.14101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 06/18/2023]
Abstract
People often use cognitive and affective heuristics when judging the likelihood of a health outcome and making health decisions. However, little research has examined how heuristics shape risk perceptions and behavior among people who make decisions on behalf of another person. We examined associations between heuristic cues and caregivers' perceptions of their child's asthma risk, the frequency of caregivers' asthma management behaviors, and child health outcomes. We used Ipsos KnowledgePanel to recruit 814 U.S. adult caregivers of children with asthma of the age <18 years. Participants completed a survey at baseline (T1) and 3 months later (T2). Caregivers who, at T1, reported greater negative affect about their child's asthma (affect heuristic cue), greater ease of imagining their child experiencing asthma symptoms (availability heuristic cue), and greater perceived similarity between their child and a child who has ever experienced asthma symptoms (representativeness heuristic cue) reported statistically significantly (p < 0.05) higher interpersonal perceived risk of their child having an exacerbation or uncontrolled asthma at T1. They also indicated at T2 that their child had poorer asthma control and more frequent exacerbations. Greater T1 negative affect was associated with more frequent T2 actions to reduce inflammation, manage triggers, and manage symptoms, and with poorer T2 child health outcomes. Heuristic cues are likely important for interpersonal-not just personal-risk perceptions. However, the interrelationship between caregivers' ratings of heuristic cues (in particular, negative affect) and risk judgments may signify a struggle with managing their child's asthma and need for extra support from health care providers or systems.
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Affiliation(s)
- Erika A. Waters
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | | | | | - Jean Hunleth
- Washington University in St. Louis, Saint Louis, Missouri, USA
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Pender K. Cracking open the eristic rhetoric of contralateral prophylactic mastectomy research or why surgeons should not be so certain about this controversial breast cancer treatment. MEDICAL HUMANITIES 2023; 49:378-389. [PMID: 36549858 DOI: 10.1136/medhum-2022-012460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
Contralateral prophylactic mastectomy (CPM) is a controversial breast cancer treatment in which both breasts are removed when only one is affected by cancer. Rates of CPM have been rising since the late 1990s, despite surgeons' strong agreement that the procedure should not be performed for average-risk women. This essay analyses that agreement as it is demonstrated in the surgical literature on CPM, arguing that it forms a 'rhetoric of certainty' built on the stark epistemological divide between objective and subjective forms of knowledge that operates in some areas of medicine. Further, the essay argues that this rhetoric of certainty has the potential to function as a kind of eristic rhetoric in which the right conclusion is known prior to any rhetorical exchange. As a way to 'crack open' this certainty, the essay compares the rhetoric of the surgical literature on CPM to the rhetoric of uncertainty in the radiological literature on breast cancer screening for women with a personal history of the disease. The goal of this comparison is not to suggest surgeons should support all choices for CPM. Rather, the aim is to demonstrate that choices against the procedure are not as straightforward as the surgical literature indicates and that the uncertainty affecting women's preferences for CPM is not solely the result of patient misunderstanding and/or emotional instability.
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Mamtani A, Sjoberg DD, Vincent A, Ehdaie B, Malhotra D, Vickers A, Morrow M. Does a brief surgeon training in negotiation theory principles decrease rates of contralateral prophylactic mastectomy? Breast Cancer Res Treat 2023; 199:119-126. [PMID: 36881270 PMCID: PMC10542969 DOI: 10.1007/s10549-023-06891-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/08/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Despite the lack of any oncologic benefit, contralateral prophylactic mastectomy (CPM) use among women with unilateral breast cancer is increasing. This patient-driven trend is influenced by fear of recurrence and desire for peace of mind. Traditional educational strategies have been ineffective in reducing CPM rates. Here we employ training in negotiation theory strategies for counseling and determine the effect on CPM rates. METHODS In consecutive patients with unilateral breast cancer treated with mastectomy from 05/2017 to 12/2019, we examined CPM rates before and after a brief surgeon training in negotiation skills. This comprised a systematic framework for patient counseling utilizing early setting of the default option, leveraging social proof, and framing. RESULTS Among 2144 patients, 925 (43%) were treated pre-training and 744 (35%) post-training. Those treated in the 6-month transition period were excluded (n = 475, 22%). Median patient age was 50 years; most patients had T1-T2 (72%), N0 (73%), and estrogen receptor-positive (80%) tumors of ductal histology (72%). The CPM rate was 47% pre-training versus 48% post-training, with an adjusted difference of -3.7% (95% CI -9.4 to 2.1, p = 0.2). In a standardized self-assessment survey, all 15 surgeons reported a high baseline use of negotiation skills and no significant change in conversational difficulty with the structured approach. CONCLUSION Brief surgeon training did not affect self-reported use of negotiation skills or reduce CPM rates. The choice of CPM is a highly individual decision influenced by patient values and decision styles. Further research to identify effective strategies to minimize surgical overtreatment with CPM is needed.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
| | - Daniel D Sjoberg
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alain Vincent
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Behfar Ehdaie
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deepak Malhotra
- Negotiation, Organizations, and Markets Unit, Harvard Business School, Boston, MA, USA
| | - Andrew Vickers
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Comeaux JG, Culver JO, Lee JE, Dondanville D, McArthur HL, Quinn E, Gorman N, Ricker C, Li M, Lerman C. Risk‐reducing mastectomy decisions among women with mutations in high‐ and moderate‐ penetrance breast cancer susceptibility genes. Mol Genet Genomic Med 2022; 10:e2031. [PMID: 36054727 PMCID: PMC9544212 DOI: 10.1002/mgg3.2031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/25/2022] [Indexed: 12/02/2022] Open
Abstract
Background Women harboring mutations in breast cancer susceptibility genes are at increased lifetime risk of developing breast cancer and are faced with decisions about risk management, including whether to undergo high‐risk screening or risk‐reducing mastectomy (RRM). National guidelines recommend BRCA1 or BRCA2 mutation carriers consider RRM, but that carriers of moderate penetrance mutations (e.g., ATM or CHEK2) should be managed based on family history. We aimed to investigate determinants of decision for RRM, and hypothesized that mutation status, age, family history, partner status, and breast cancer would impact RRM decision making. Methods We performed a retrospective study assessing RRM decisions for 279 women. Results Women with BRCA and moderate penetrance gene mutations, a personal history of breast cancer, or a first degree relative with a history of breast cancer were more likely to undergo RRM. Breast cancer status and age showed an interaction effect such that women with breast cancer were less likely to undergo RRM with increasing age. Conclusion Although national guidelines do not recommend RRM for moderate penetrance carriers, the rates of RRM for this population approached those for BRCA mutation carriers. Further insights are needed to better support RRM decision‐making in this population.
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Affiliation(s)
- Jacob G. Comeaux
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Julie O. Culver
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - John E. Lee
- Samuel Oschin Cancer CenterCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | - Heather L. McArthur
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Emily Quinn
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Nicholas Gorman
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Charité Ricker
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ming Li
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Caryn Lerman
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Krasniak PJ, Nguyen M, Janse S, Phommasathit C, Clevenger K, Renshaw S, Agnese DM, Padamsee TJ, Lee CN. Emotion and Contralateral Prophylactic Mastectomy: A Prospective Study into Surgical Decision-Making. Psychooncology 2022; 31:1711-1718. [PMID: 35946336 DOI: 10.1002/pon.6013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/22/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Patients with non-familial, unilateral breast cancer have a low risk of contralateral breast cancer. Thus, clinical studies have shown no survival benefit for patients who undergo contralateral prophylactic mastectomy (CPM) compared to those undergoing unilateral surgeries for non-familial unilateral breast cancers. Despite this evidence, there has been a steady increase in rates of CPM in the U.S. Patient factors influencing this choice have been identified in previous studies, but seldom in a prospective manner. This prospective study was designed to assess emotion and any association with a patient's decision to ultimately undergo CPM. METHODS We recruited patients with newly diagnosed, unilateral, non-metastatic breast cancer, who had not yet had surgery, to participate in a prospective, longitudinal study to examine the impact of emotions on CPM decision-making. RESULTS Among the 86 final participants, all completed the pre-visit survey (100%) and 52 patients completed the post-visit survey (60%). Patients undergoing CPM were significantly younger than those who did not. There was no statistically significant association between emotion and receipt of CPM. There was a trend towards undergoing CPM in patients with a less open personality type and those with more negative emotion, though not statistically significant. CONCLUSIONS This study found a trend toward increased CPM receipt in those with less open personality types and more negative emotion, especially post-consultation, but none of these findings was significant. Future work should include development of cancer-specific emotion scales and larger studies of possible connections between emotion, personality type and surgical decision-making for breast cancer patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peter J Krasniak
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Minh Nguyen
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sarah Janse
- Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Crystal Phommasathit
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Kaleigh Clevenger
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Savannah Renshaw
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Doreen M Agnese
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tasleem J Padamsee
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Clara N Lee
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,The James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA.,College of Public Health, The Ohio State University, Columbus, Ohio, USA
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A Comparison of Complications in Therapeutic versus Contralateral Prophylactic Mastectomy Reconstruction: A Paired Analysis. Plast Reconstr Surg 2022; 149:1037-1047. [PMID: 35245238 DOI: 10.1097/prs.0000000000008981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear. METHODS Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient. RESULTS A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)]. CONCLUSION Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Pender K, Covington B. How Contralateral Prophylactic Mastectomy Does the Body, or Why Epistemology Alone Cannot Explain this Controversial Breast Cancer Treatment. THE JOURNAL OF MEDICAL HUMANITIES 2022; 43:141-158. [PMID: 32043198 DOI: 10.1007/s10912-020-09614-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Since the late 1990s, the use of contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer has been on the rise. Over the past two decades, dozens of studies have been conducted in order to understand this trend, which has puzzled and frustrated physicians who find it at odds with efforts to curb the surgical overtreatment of breast cancer, as well as with evidence-based medicine, which has established that the procedure has little oncologic benefit for most patients. Based on the work of Annemarie Mol and John Law, this paper argues that these efforts to understand increased CPM use are limited by the "epistemology problem" in medicine, or, in other words, the tendency to view healthcare controversies and decision making exclusively through the lenses of objective and subjective forms of knowledge. Drawing on public discourse about rationales for choosing CPM, we argue that this surgical trend cannot adequately be understood in terms of what doctors and patients know about breast cancer risk and how CPM affects that risk. In addition, it must be recognized as the outcome of how specific practices of screening, detection, and treatment do or enact the bodies of patients, producing tensions in their lives that cannot be remedied with better or better communicated information. Recognizing the embodied realities of these enactments and their effects on patient decision making, we maintain, is essential for physicians who want to avoid the paternalism that haunts breast cancer treatment in the US.
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Affiliation(s)
- Kelly Pender
- Virginia Tech, 232 Shanks Hall (0112), 181 Turner St. NW, Blacksburg, VA, 24061, USA.
| | - Brooke Covington
- Virginia Tech, 232 Shanks Hall (0112), 181 Turner St. NW, Blacksburg, VA, 24061, USA
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Jansen J, Serafimovska A, Glassey R, Zdenkowski N, Saunders C, Porter D, Butow P. The implementation of a decision aid for women with early-stage breast cancer considering contralateral prophylactic mastectomy: A pilot study. PATIENT EDUCATION AND COUNSELING 2022; 105:74-80. [PMID: 34034935 DOI: 10.1016/j.pec.2021.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Despite little survival benefit and potential for harm, contralateral prophylactic mastectomy (CPM) rates are increasing amongst early-stage breast cancer patients at low contralateral breast cancer risk. We developed a CPM decision aid (DA) and conducted a pilot implementation. METHODS Surgeons and oncologists recruited eligible patients considering CPM. Consenting patients received the DA, completed a questionnaire and participated in a semi-structured interview. Clinicians were interviewed at study close. RESULTS Eleven clinicians and 31 patients participated. Three themes emerged: perceived utility and impact of the DA, disagreement regarding timing of delivery and target population, and implementation strategies. Both women and clinicians found the DA valuable, indicating it confirmed rather than changed preferences. Women (all of whom raised CPM themselves), preferred offering the DA early in treatment discussions whilst clinicians favoured targeting women who enquired about CPM. CONCLUSION A DA about CPM is feasible and acceptable, but questions remain about the role of DAs in these types of decisions where one option has limited medical benefit. PRACTICE IMPLICATIONS Some women have a high need to make an informed choice about CPM. Tools to support this could include a DA with a clear recommendation against CPM and an explanation why.
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Affiliation(s)
- J Jansen
- Department of Family Medicine, School Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Peter Debyeplein 1, 6229 HA Maastricht, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
| | - A Serafimovska
- Centre for Medical Psychology and Evidence-based Decision-making, School of Psychology, University of Sydney, Australia
| | - R Glassey
- School of Medicine, University of Western Australia, Perth, Australia
| | - N Zdenkowski
- Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia; Breast Cancer Trials, Newcastle, Australia
| | - C Saunders
- School of Medicine, University of Western Australia, Perth, Australia
| | | | - P Butow
- Centre for Medical Psychology and Evidence-based Decision-making, School of Psychology, University of Sydney, Australia
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Hovis K, Mercaldo S, Kim G, Lamb LR, Oseni TO, Bahl M. Contralateral breast cancer after curative-intent treatment for ductal carcinoma in situ: Rate and associated clinicopathological and imaging risk factors. Clin Imaging 2021; 82:179-192. [PMID: 34872008 DOI: 10.1016/j.clinimag.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/24/2021] [Accepted: 11/14/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Patients who have ductal carcinoma in situ (DCIS) are undergoing bilateral mastectomy at increasing rates. One of the reasons is to minimize contralateral breast cancer (CBC) risk. The purpose of this study is to determine the rate of and risk factors associated with CBC in women treated for DCIS. METHODS A retrospective study was performed of women with DCIS at surgery from 2007 to 2014 who had at least five-year follow-up. Patient attributes, imaging findings, histopathology results, and surgical and long-term outcomes were collected. Features associated with a CBC were assessed with multivariable logistic regression models. RESULTS 613 women (mean 56 years, range 30-87) with DCIS underwent breast-conserving surgery (BCS) (n = 426), unilateral mastectomy (n = 101), or bilateral mastectomy (n = 86), with mean follow-up of 7.9 years. Of the 527 women who had BCS or unilateral mastectomy, 7.4% (n = 39) developed a CBC (DCIS in 12 and invasive cancer in 27). 4.1% (5/122) of women treated with adjuvant endocrine therapy developed a CBC, compared to 8.4% (34/405) who were not treated (p = .11). Features associated with CBC risk were younger age at menarche (adjusted odds ratio [aOR] of 0.76, p = .03) and low nuclear grade of DCIS (aOR of 5.43 for grade 1 versus 3, p = .01). CONCLUSION In women treated for DCIS, the overall rate of CBC was low at 7.4%. Younger age at menarche and low nuclear grade of DCIS had significant associations with higher CBC risk.
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Affiliation(s)
- Keegan Hovis
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street (WAC 240), Boston, MA 02114, USA
| | - Sarah Mercaldo
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street (WAC 240), Boston, MA 02114, USA
| | - Geunwon Kim
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street (WAC 240), Boston, MA 02114, USA
| | - Leslie R Lamb
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street (WAC 240), Boston, MA 02114, USA
| | - Tawakalitu O Oseni
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Manisha Bahl
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street (WAC 240), Boston, MA 02114, USA.
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Abstract
Breast surgical oncology is a rapidly evolving field with significant advances shaped by practice-changing research. Three areas of ongoing controversy are (1) high rates of contralateral prophylactic mastectomy (CPM) in the United States despite uncertain benefit, (2) indications for and use of neoadjuvant chemotherapy (NACT) and endocrine therapy (NET), and (3) staging and treatment of the axilla, particularly after neoadjuvant systemic therapy. We discuss the patient populations for whom CPM may or may not be beneficial, indications for NACT and NET, and the trend toward de-escalation of locoregional axillary treatment.
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Affiliation(s)
- Lily Gutnik
- Duke University School of Medicine, DUMC 3513, Durham, NC 27707, USA. https://twitter.com/LGutnik
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11
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Smith J, Dodd RH, Gainey KM, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review. JAMA Netw Open 2021; 4:e2133406. [PMID: 34748004 PMCID: PMC8576581 DOI: 10.1001/jamanetworkopen.2021.33406] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened. OBJECTIVE To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer. EVIDENCE REVIEW Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020. FINDINGS The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop. CONCLUSIONS AND RELEVANCE Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.
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Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachael H. Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Karen M. Gainey
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kirsten J. McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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12
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Ha M, Ngaage LM, Klein M, Yang A, Colohan SM, Nurudeen SM, Terhune JH, Slezak S, Rasko YM. Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States. Breast J 2021; 27:746-752. [PMID: 34528334 DOI: 10.1111/tbj.14280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Contralateral prophylactic mastectomy (CPM) is more common in the United States than the rest of the world. However, the benefit of this procedure is still under question in many breast cancer scenarios. CPM utilization in the United States is in part dependent on a patient's health insurance coverage of breast oncology surgery and any desired reconstruction. However, there are great discrepancies in the coverage provided by insurers. METHODS The authors conducted a cross-sectional analysis of insurance policies for a CPM in the setting of diagnosed breast cancer. One hundred companies were selected based on their state enrollment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS Of the 100 companies assessed, 36 (36%) had a policy for CPM. Within those, significantly more provided coverage than denied the procedure (72% vs. 25%, p < 0.0001), with the remainder providing case-by-case coverage. Eleven criteria were identified from preauthorized policies, the most common prerequisite was breast cancer diagnosis under 45 years old (n = 9, 35%). Most policies did not differentiate between gender in their policies (n = 25, 69%), but of those that did, 100% (n = 11) provided coverage for men and women, with 82% (n = 9) requiring further criteria from the female patients. CONCLUSION The coverage of CPM in the United States varies from complete denial to unrestricted approval. This may be due to conflicting reports in the literature as to the utility of the procedure. The decision to undergo this procedure must be taken with thoughtful consideration and the support of a multidisciplinary approach.
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Affiliation(s)
- Michael Ha
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marissa Klein
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Annie Yang
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Shannon M Colohan
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Suliat M Nurudeen
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julia H Terhune
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sheri Slezak
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Deliere A, Attai D, Victorson D, Kuchta K, Pesce C, Kopkash K, Sisco M, Seth A, Yao K. Patients Undergoing Bilateral Mastectomy and Breast-Conserving Surgery Have the Lowest Levels of Regret: The WhySurg Study. Ann Surg Oncol 2021; 28:5686-5697. [DOI: 10.1245/s10434-021-10452-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/08/2021] [Indexed: 12/23/2022]
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Wang T, Bredbeck BC, Sinco B, Shubeck S, Baskin AS, Skolarus T, Dossett LA. Variations in Persistent Use of Low-Value Breast Cancer Surgery. JAMA Surg 2021; 156:353-362. [PMID: 33533894 PMCID: PMC7859877 DOI: 10.1001/jamasurg.2020.6942] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/23/2020] [Indexed: 12/19/2022]
Abstract
Importance Through the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation. Objective To identify variation and determinants of persistent use of low-value breast cancer surgical care. Design, Setting, and Participants Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation. Main Outcomes and Measures Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission. Results The total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another. Conclusions and Relevance Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and performance.
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Affiliation(s)
- Ton Wang
- Department of Surgery, Michigan Medicine, Ann Arbor
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor
| | - Brooke C. Bredbeck
- Department of Surgery, Michigan Medicine, Ann Arbor
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor
| | - Brandy Sinco
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor
| | - Sarah Shubeck
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alison S. Baskin
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor
- University of Michigan School of Medicine, Ann Arbor
| | - Ted Skolarus
- Department of Urology, Michigan Medicine, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lesly A. Dossett
- Department of Surgery, Michigan Medicine, Ann Arbor
- Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor
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Baskin AS, Wang T, Bredbeck BC, Sinco BR, Berlin NL, Dossett LA. Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer. J Surg Res 2021; 262:71-84. [PMID: 33548676 DOI: 10.1016/j.jss.2020.12.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/01/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. METHODS Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. RESULTS Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models. CONCLUSIONS Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.
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Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brooke C Bredbeck
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brandy R Sinco
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Park SY, Kim Y, Kim S. Factors associated with the decision to undergo risk-reducing salpingo-oophorectomy among women at high risk for hereditary breast and ovarian cancer: a systematic review. KOREAN JOURNAL OF WOMEN HEALTH NURSING 2020; 26:285-299. [PMID: 36312308 PMCID: PMC9328615 DOI: 10.4069/kjwhn.2020.11.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose This systematic review aims to identify factors associated with risk-reducing salpingo-oophorectomy (RRSO), including the uptake rate and decision timing, among women at high risk for hereditary breast and ovarian cancer (HBOC). Methods We found 4,935 relevant studies using MEDLINE, Embase, CINAHL, and PsycINFO on July 6, 2020. Two authors screened the articles and extracted data. Twenty-four studies met the inclusion criteria. Quality assessment of articles was conducted using the Risk of Bias for Nonrandomized Studies tool. Results Five types of factors were identified (demographic factors, clinical factors, family history of cancer, psychological factors, and objective cancer risk). The specific significant factors were older age, having child(ren), being a BRCA1/2 carrier, mastectomy history, perceived risk for ovarian cancer, and perceived advantages of RRSO, whereas objective cancer risk was not significant. The uptake rate of RRSO was 23.4% to 87.2% (mean, 45.2%) among high-risk women for HBOC. The mean time to decide whether to undergo RRSO after BRCA testing was 4 to 34 months. Conclusion RRSO decisions are affected by demographic, clinical, and psychological factors, rather than objective cancer risk. Nonetheless, women seeking RRSO should be offered information about objective cancer risk. Even though decision-making for RRSO is a complex and multifaceted process, the psychosocial factors that may influence decisions have not been comprehensively examined, including family attitudes toward RRSO, cultural norms, social values, and health care providers’ attitudes.
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Affiliation(s)
- Sun-young Park
- Graduate School, Yonsei University, Seoul, Korea
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Youlim Kim
- Graduate School, Yonsei University, Seoul, Korea
- Mo-Im Kim Nursing Research Institute and College of Nursing, Yonsei University, Seoul, Korea
| | - Sue Kim
- Mo-Im Kim Nursing Research Institute and College of Nursing, Yonsei University, Seoul, Korea
- Corresponding author: Sue Kim College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2228-3276 E-mail:
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The relationship between contralateral prophylactic mastectomy and breast reconstruction, complications, breast-related procedures, and costs: A population-based study of health insurance data. Surgery 2020; 168:859-867. [DOI: 10.1016/j.surg.2020.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/09/2020] [Accepted: 06/18/2020] [Indexed: 12/20/2022]
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Pesce C, Jaffe J, Kuchta K, Yao K, Sisco M. Patient-reported outcomes among women with unilateral breast cancer undergoing breast conservation versus single or double mastectomy. Breast Cancer Res Treat 2020; 185:359-369. [PMID: 33033966 DOI: 10.1007/s10549-020-05964-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer. METHODS We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15 months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal-Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point. RESULTS 203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15 months, it was significantly lower in BM patients than in BCT patients. Women who felt "very" confident and "very" informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15 months. CONCLUSION While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.
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Affiliation(s)
- Catherine Pesce
- Department of Surgery, Division of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, USA
| | - Jennifer Jaffe
- Department of Surgery, Division of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, USA
| | - Kristine Kuchta
- Biostatistical Core, NorthShore University HealthSystem Research Institute, Evanston, IL, USA
| | - Katharine Yao
- Department of Surgery, Division of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, USA
| | - Mark Sisco
- Department of Surgery, Division of Plastic Surgery, NorthShore University HealthSystem, Northbrook, IL, USA.
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Wang T, Baskin AS, Dossett LA. Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery. JAMA Surg 2020; 155:759-770. [PMID: 32492121 PMCID: PMC10185302 DOI: 10.1001/jamasurg.2020.0322] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Overtreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer. Objective To evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation. Evidence Review A systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use. Findings Concordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes. Conclusions and Relevance This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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20
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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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21
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Srethbhakdi A, Brennan ME, Hamid G, Flitcroft K. Contralateral prophylactic mastectomy for unilateral breast cancer in women at average risk: Systematic review of patient reported outcomes. Psychooncology 2020; 29:960-973. [PMID: 32201988 DOI: 10.1002/pon.5379] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/23/2020] [Accepted: 03/03/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The rate of contralateral prophylactic mastectomy (CPM) in women with early, unilateral cancer is relatively high and is increasing around the world a previous study. Women choose this option for many reasons other than reducing their risk of future cancer, including symmetry, reasons related to breast reconstruction and attempting to manage fear of recurrence. This systematic review evaluated patient-reported quality of life outcomes following CPM. METHODS A literature search of MEDLINE, PubMed and PsycINFO was performed to February 2019. Abstracts and full-text articles were assessed for eligibility according to pre-determined criteria. Data were extracted into evidence tables for analysis. RESULTS A total of 19 articles met eligibility criteria and were included in analysis. These included patient-reported data from 6088 women undergoing CPM. They reported high levels of satisfaction with the decision for surgery, low levels of decisional regret and high satisfaction with cosmesis and reconstruction. Breast-specific and general quality of life was high overall but was even better in women choosing breast reconstruction after surgery. Fear of cancer recurrence was high after CPM. Depression, distress and a negative impact on body image were evident; however, levels were high in both CPM and non-CPM groups. CONCLUSIONS This study provides information that can be used by surgeons and psychologists when counselling women about the potential benefits and harms of CPM. This process must include discussion about the trade-offs such as body image issues and ongoing fear of recurrence in addition to the positive aspect of cancer risk reduction. Women are unlikely to regret their decision for CPM.
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Affiliation(s)
- Amilee Srethbhakdi
- School of Medicine, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Meagan E Brennan
- School of Medicine, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- School of Medicine, Sydney, University of Notre Dame, Chippendale, New South Wales, Australia
| | - Geaty Hamid
- Westmead Breast Cancer Institute, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kathy Flitcroft
- School of Medicine, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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Teoh V, Tasoulis MK, Gui G. Contralateral Prophylactic Mastectomy in Women with Unilateral Breast Cancer Who Are Genetic Carriers, Have a Strong Family History or Are just Young at Presentation. Cancers (Basel) 2020; 12:E140. [PMID: 31935898 PMCID: PMC7016894 DOI: 10.3390/cancers12010140] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 01/02/2023] Open
Abstract
The uptake of contralateral prophylactic mastectomy is rising with increasing trends that are possibly highest in the USA. Whilst its role is generally accepted in carriers of recognized high-risk predisposition genes such as BRCA1 and BRCA2 when the affected individual is premenopausal, controversy surrounds the benefit in less understood risk-profile clinical scenarios. This comprehensive review explores the current evidence underpinning the role of contralateral prophylactic mastectomy and its impact on contralateral breast cancer risk and survival in three distinct at-risk groups affected by unilateral breast cancer: known genetic carriers, those with strong familial risk but no demonstrable genetic mutation and women who are of young age at presentation. The review supports the role of contralateral prophylactic mastectomy in "high risk" groups where the evidence suggests a reduction in contralateral breast cancer risk. However, this benefit is less evident in women who are just young at presentation or those who have strong family history but no demonstrable genetic mutation. A multidisciplinary and personalized approach to support individuals in a shared-decision making process is recommended.
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Affiliation(s)
- Victoria Teoh
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, Fulham Road, London SW36JJ, UK; (M.-K.T.); (G.G.)
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Kantor O, Chang C, Bleicher RJ, Moran M, Connolly JL, Kurtzman SH, Yao K. Physician Knowledge of Breast Cancer Recurrence and Contralateral Breast Cancer Risk is Associated with Increased Recommendations for Contralateral Prophylactic Mastectomy: a Survey of Physicians at NAPBC-Accredited Centers. Ann Surg Oncol 2019; 26:3080-3088. [PMID: 31342369 DOI: 10.1245/s10434-019-07559-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Indexed: 07/03/2024]
Abstract
BACKGROUND Physician recommendation for contralateral prophylactic mastectomy (CPM) has been shown to influence whether a patient chooses CPM. Few studies have explored physician knowledge about contralateral breast cancer (CBC) and local recurrence (LR) risk and whether knowledge is associated with recommendation for CPM. METHODS We conducted a cross-sectional survey of physicians at National Accreditation Program for Breast Centers-accredited breast centers across the USA. Physician knowledge levels of CBC and LR were assessed and correlated with recommendations for CPM. RESULTS A total of 2412 physicians were surveyed with a 51% response rate (n = 1226). The results showed that 66% had correct knowledge about CBC risk and 57% had correct knowledge about LR. Moreover, 634 had high knowledge, viz. 176 (55.4%) breast surgeons, 171 (58.0%) medical oncologists, 196 (62.0%) radiation oncologists, and 72 (29.9%) plastic surgeons (p < 0.01). Compared with high knowledge, low knowledge was associated with favoring insurance coverage for patients at average CBC risk (53.8% vs. 39.8%, p < 0.01). Low knowledge was also associated with feeling that CPM was indicated in patients with high recurrence anxiety (39.2% vs. 28.9%), young patients with estrogen receptor (ER)-negative cancer (25.3% vs. 18.5%), and patients with two first-degree relatives with breast cancer (40.0% vs. 32.3%) (all p < 0.01). Multivariable analysis found physician type [odds ratio (OR) 3.76 for surgeons] and low knowledge (OR 1.46) to be significant independent predictors of favoring insurance coverage for CPM in patients at average risk. CONCLUSIONS Physician knowledge about CBC and LR could be improved. Lower knowledge is associated with favorable physician recommendations for CPM. It is not clear whether improving physician knowledge will change recommendations for CPM.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Cecilia Chang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, USA
| | | | - Meena Moran
- Department of Radiology, Yale Medicine, New Haven, CT, USA
| | - James L Connolly
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Katharine Yao
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
- Pritzker School of Medicine, University of Chicago, Chicago, USA.
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Manne S, Smith B, Mitarotondo A, Frederick S, Toppmeyer D, Kirstein L. Decisional conflict among breast cancer patients considering contralateral prophylactic mastectomy. PATIENT EDUCATION AND COUNSELING 2019; 102:902-908. [PMID: 30553577 PMCID: PMC7666877 DOI: 10.1016/j.pec.2018.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 12/04/2018] [Accepted: 12/08/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The study's goals were to characterize decisional conflict and preparedness for making the decision about having CPM among breast cancer patients considering CPM who do not carry cancer-predisposing mutation and to evaluate correlates of decisional conflict and preparedness. METHODS 93 women considering CPM completed a survey of decisional conflict and preparedness for the CPM decision, knowledge, perceived risk, self-efficacy, reasons for CPM, input from others and discussion with the doctor about CPM, and cancer worry. RESULTS Between 8% and 27% of women endorsed elevated decisional conflict. Most women were satisfied with preparatory information that they were provided. Knowledge was low. Top reasons for choosing CPM were the desire for peace of mind, lowering the chance of another breast cancer, and improving survival. CONCLUSIONS Decisional conflict is elevated in a subset of patients considering CPM. A more well-informed decision may be fostered by a comprehensive discussion about CPM with the patient's clinician, fostering self-efficacy in managing cancer worry, and helping patients understand their motivations for CPM. PRACTICE IMPLICATIONS Clinicians working with breast cancer patients considering CPM should discuss the CPM decision, foster self-efficacy in managing cancer worry, and help patients understand their motivations for the surgery.
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Affiliation(s)
- Sharon Manne
- Section of Population Science, Department of Medicine, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, USA.
| | - Barbara Smith
- Center for Breast Cancer, Massachusetts General Hospital, Boston, USA
| | - Anna Mitarotondo
- Section of Population Science, Department of Medicine, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Sara Frederick
- Section of Population Science, Department of Medicine, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Deborah Toppmeyer
- Section of Population Science, Department of Medicine, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
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Tollow P, Williams VS, Harcourt D, Paraskeva N. “It felt like unfinished business, it feels like that's finished now”: Women's experiences of decision making around contralateral prophylactic mastectomy (CPM). Psychooncology 2019; 28:1328-1334. [PMID: 30963646 DOI: 10.1002/pon.5086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Philippa Tollow
- Centre for Appearance ResearchUniversity of the West of England Bristol UK
| | | | - Diana Harcourt
- Centre for Appearance ResearchUniversity of the West of England Bristol UK
| | - Nicole Paraskeva
- Centre for Appearance ResearchUniversity of the West of England Bristol UK
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26
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Herwig A, Dehnen D, Weltermann B. Patient factors driving overuse of cardiac catheterisation: a qualitative study with 25 participants from two German teaching practices. BMJ Open 2019; 9:e024600. [PMID: 30975669 PMCID: PMC6500255 DOI: 10.1136/bmjopen-2018-024600] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Percutaneous coronary interventions do not provide a benefit over medical therapy for stable patients. However, an overuse of cardiac catheterisation (CC) for stable coronary artery disease (CAD) is documented in Germany and other countries. In this study, we aim to understand patient factors that foster this overuse. DESIGN Our study is an exploratory qualitative interview study with narrative, structured interviews. The interviews were analysed using qualitative content analysis by Mayring. SETTING The interviews were conducted in two German teaching practices. PARTICIPANTS 24 interviews with 25 patients were conducted; 17 (68%) patients were male, the average age was 73.9 years (range 53-88 years). All patients suffered from CAD and had undergone at least one CC. Patients with known anxiety disorders were excluded from the study. RESULTS The analysis identified six patient factors which contributed to or prevented the overuse of CC: (1) unquestioned acceptance of prescheduled appointments for procedures/convenience; (2) disinterest in and/or lack of disease-specific knowledge; (3) helplessness in situations with varying opinions on the required care; (4) fear of another cardiac event, (5) patient-physician relationship and (6) the patient's experience that repeat interventions did not result in a change of health status or care. CONCLUSIONS Conducted in a country with documented overuse of CC, we showed that most patients trusted their physicians' recommendations for repeat coronary angiographies even if they were asymptomatic. Strategies to align physician adherence with guidelines and corresponding patient information are needed to prevent overuse.
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Affiliation(s)
- Anna Herwig
- Institute for General Medicine, University Hospital Essen, Essen, Germany
| | - Dorothea Dehnen
- Institute for General Medicine, University Hospital Essen, Essen, Germany
| | - Birgitta Weltermann
- Institute for General Medicine, University Hospital Essen, Essen, Germany
- Institute for General Practice and Family Medicine, University Hospital Bonn, Bonn, Germany
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Chen H, Zhang P, Zhang M, Wang M, Bai F, Wu K. Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer. J Surg Res 2019; 239:224-232. [PMID: 30856515 DOI: 10.1016/j.jss.2019.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the trends of surgical treatments among young patients in T1N0-1M0 stage based on the Surveillance, Epidemiology, and End Results database. MATERIALS AND METHODS Patients aged less than 40 y diagnosed between 1998 and 2015 were enrolled, with tumors in T1N0-1M0 stage and not located in the central area. Differences in clinical-pathological characteristics were evaluated using chi-square tests. Multivariate logistic regression was used to measure the various factors associated with contralateral prophylactic mastectomy (CPM). Independent prognostic factors were evaluated by Cox model. RESULTS The total rate of breast-conserving surgery (BCS) was 51.6%, which declined from 64.5% in 1998 to 39.6% in 2015. The total rate of CPM was 22.7%, which increased from 3.7% in 1998 to 38.7% in 2014 despite a decline to 32.7% in 2015. Meanwhile, the rate of reconstruction increased in line with that of CPM, from 9.4% in 1998 to 35.0% in 2015. There was a trend of increasing use of implant-based reconstruction. Significant higher odds of CPM were found in recent year of diagnosis between 2010 and 2015 and in implant-based reconstruction. Patients undergoing CPM had similar survival outcomes compared with those undergoing BCS and unilateral mastectomy, whereas those undergoing BCS had better survival outcomes compared with those undergoing unilateral mastectomy. CONCLUSIONS A trend of growing preference for CPM and reconstruction was observed among young patients in early stage in recent years without survival benefits. Efforts should be made to promote efficient communication and evidence-based decision-making.
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Affiliation(s)
- Hongliang Chen
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Peng Zhang
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Mingdi Zhang
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Maoli Wang
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Fang Bai
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Kejin Wu
- Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
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Jerome-D'Emilia B, Trinh H. Socioeconomic Factors Associated with the Receipt of Contralateral Prophylactic Mastectomy in Women with Breast Cancer. J Womens Health (Larchmt) 2019; 29:220-229. [PMID: 30759049 DOI: 10.1089/jwh.2018.7350] [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] [Indexed: 01/11/2023] Open
Abstract
Background: Contralateral prophylactic mastectomy (CPM) treatments have been on the rise among white women with early stage unilateral breast cancer who have a higher socioeconomic status (SES) and private insurance. Low income and uninsured women are not choosing CPM at the same rate. The purpose of this study was to evaluate the socioeconomic factors related to the choice of surgical treatment in women diagnosed with unilateral breast cancer in the state of New Jersey. Materials and Methods: This retrospective study of 10 years of breast cancer data abstracted from the New Jersey State Cancer Registry utilized bivariate analyses and two multivariate logistic regression models to analyze the effect of socioeconomics on choice of surgical treatment. Results: In New Jersey, 52,529 women were treated for breast cancer from 2004 to 2014. CPM rates increased gradually over time from 3.72% in 2004 to 10.82% in 2014 with women more likely to choose CPM if they were younger, white, and had private insurance (p < 0.001). The single factor that was most predictive of choosing CPM was access to immediate reconstruction (odds ratio 2.36, confidence interval 2.160-2.551). Women with low SES were much less likely to choose CPM. Conclusions: Results of this study may provide incentive for researchers to assess the impact of culture, race/ethnicity, and socioeconomics on a woman's interactions with health care providers so as to allow all women regardless of SES to express their needs, concerns, and wishes when confronted with a breast cancer diagnosis.
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Affiliation(s)
| | - Hanh Trinh
- Department of Health Informatics & Administration, University of Wisconsin, Madison, Wisconsin
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29
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Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology. Ann Surg 2019; 267:271-279. [PMID: 28594745 DOI: 10.1097/sla.0000000000002309] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To reach a consensus about contralateral prophylactic mastectomy in unilateral breast cancer. SUMMARY BACKGROUND DATA There has been a substantial increase in the number of North American women with unilateral breast cancer undergoing a therapeutic mastectomy and a contralateral prophylactic mastectomy (CPM) either simultaneously or sequentially. The purpose of this project was to create a nationally endorsed consensus statement for CPM in women with unilateral breast cancer using modified Delphi consensus methodology. METHODS A nationally representative expert panel of 19 general surgeons, 2 plastic surgeons, 2 medical oncologists, 2 radiation oncologists, and 1 psychologist was invited to participate in the generation of a consensus statement. Thirty-nine statements were created in 5 topic domains: predisposing risk factors for breast cancer, tumor factors, reconstruction/symmetry issues, patient factors, and miscellaneous factors. Panelists were asked to rate statements on a 7-point Likert scale. Two electronic rounds of iterative rating and feedback were anonymously completed, followed by an in-person meeting. Consensus was reached when there was at least 80% agreement. RESULTS Our panelists did not recommend for average risk women with unilateral breast cancer. The panel recommended CPM for women with a unilateral breast cancer and previous Mantle field radiation or a BrCa1/2 gene mutation. The panel agreed that CPM could be considered by the surgeon on an individual basis for: women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 gene, and in women who may have significant difficulty achieving symmetry after unilateral mastectomy. CONCLUSION Contralateral prophylactic mastectomy is rarely recommended for women with unilateral breast cancer.
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Bloom DL, Chapman BM, Wheeler SB, McGuire KP, Lee CN, Weinfurt K, Rosenstein DL, Plichta JK, Jacobson Vann JC, Hwang ES. Reframing the conversation about contralateral prophylactic mastectomy: Preparing women for postsurgical realities. Psychooncology 2018; 28:394-400. [PMID: 30500102 DOI: 10.1002/pon.4955] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Women with unilateral, early-stage breast cancer and low genetic risk are increasingly opting for contralateral prophylactic mastectomy (CPM), a concerning trend because CPM offers few clinical benefits while increasing risks of surgical complications. Few qualitative studies have analyzed factors motivating this irreversible decision. Using qualitative methods, this study sought to understand women's decision making and the impact of CPM on self-confidence, sense of femininity, sexual intimacy, and peace of mind. METHODS Women who had CPM within the last 10 years were recruited to participate in the study. We conducted a thematic analysis of the data. RESULTS Forty-five women were interviewed. When making the decision for CPM, most had incomplete knowledge of potential negative outcomes. However, all believed CPM had more benefits than harms and would confer the most peace of mind and the fewest regrets should cancer return. They knew their contralateral breast cancer risk was low but were not persuaded by statistics. They wanted to do everything possible to reduce their risk of another breast cancer, even by a minimal amount, but most reported paying an unexpectedly high price for this small reduction in risk. Nevertheless, 41 of 45 reported that they would make the same decision again. CONCLUSIONS These findings highlight an opportunity for physicians to reframe the conversation to focus on the patient experience of the tradeoffs of CPM rather than statistical odds of future cancers. Our findings suggest that more data may not dissuade women from CPM but may better prepare them for its outcomes.
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Affiliation(s)
- Diane L Bloom
- Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brittany M Chapman
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Stephanie B Wheeler
- Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kandace P McGuire
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Clara N Lee
- Department of Plastic Surgery, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Kevin Weinfurt
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Donald L Rosenstein
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Surgery, Duke Cancer Institute, Durham, North Carolina
| | - Julie C Jacobson Vann
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.,Department of Surgery, Duke Cancer Institute, Durham, North Carolina
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31
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The Cost of Contralateral Prophylactic Mastectomy in Women with Unilateral Breast Cancer. Plast Reconstr Surg 2018; 141:1094-1102. [PMID: 29659447 DOI: 10.1097/prs.0000000000004272] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Contralateral prophylactic mastectomy may be unnecessary from an oncologic perspective; therefore, the debate persists about the value of contralateral prophylactic mastectomy in women with early-stage unilateral breast cancer. Given finite health care resources, this study aims to evaluate the cost of contralateral prophylactic mastectomy and breast reconstruction. METHODS Women with unilateral breast cancer undergoing either unilateral mastectomy or unilateral mastectomy with contralateral prophylactic mastectomy and immediate breast reconstruction were selected from the Truven MarketScan databases between 2009 and 2013. Demographic and treatment data were recorded, and over an 18-month follow-up period, the treatment cost was tallied. A log-transformed linear model was used to compare cost between the groups. RESULTS A total of 2343 women were identified who met our inclusion criteria, with 1295 undergoing unilateral mastectomy and 1048 undergoing contralateral prophylactic mastectomy. Complication rates within 18 months were similar for women undergoing unilateral mastectomy and contralateral prophylactic mastectomy (39 percent versus 42 percent; p = 0.17). Management with unilateral mastectomy with reconstruction required an adjusted cumulative mean cost of $33,557. Contralateral prophylactic mastectomy with reconstruction was an additional $11,872 in expenditure (p < 0.001). The cost of initial procedures (mean difference, $6467) and secondary procedures (mean difference, $2455) were the greatest contributors to cost. CONCLUSIONS In women with unilateral breast cancer, contralateral prophylactic mastectomy with reconstruction is more costly. The increased monetary cost of contralateral prophylactic mastectomy may be offset by improved quality of life. However, this financial reality is an important consideration when ongoing efforts toward reimbursement reform may not pay for contralateral prophylactic mastectomy if outcomes data are not presented to justify this procedure.
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32
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Mathelin C, Bruant-Rodier C. [Indications for breast reconstruction after mastectomy according to the oncological situation]. ANN CHIR PLAST ESTH 2018; 63:580-584. [PMID: 30245084 DOI: 10.1016/j.anplas.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Breast reconstruction is an integral part of breast cancer treatment. It must be systematically mentioned when the disease is announced and proposed at an optimal time during cancer management. In case of ductal carcinoma in situ, reconstruction should be proposed at the same time as mastectomy, which generally preserves the skin. The conservation of the nipple-areolar complex should be further evaluated. In the case of invasive breast carcinoma, breast reconstruction is generally proposed at a distance from the oncological time, except for patients requiring neither chemotherapy nor postoperative radiotherapy for whom reconstruction can be immediate. Finally, in the case of prophylactic synchronous contralateral mastectomy, reconstruction should never delay the overall management of breast cancer.
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Affiliation(s)
- C Mathelin
- Unité de sénologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, CHRU, 1, avenue Molière, 67098 Strasbourg cedex 09, France; Institut de génétique et de biologie moléculaire et cellulaire, biologie du cancer (IGBMC), 1, rue Laurent-Fries, 67400 Illkirch-Graffenstaden, France.
| | - C Bruant-Rodier
- Service de chirurgie esthétique et réparatrice, hôpital civil, hôpitaux universitaires de Strasbourg, CHRU, 1, place de l'hôpital, 67091 Strasbourg cedex, France
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33
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Braude L, Kirsten L, Gilchrist J, Juraskova I. The development of a template for psychological assessment of women considering risk-reducing or contralateral prophylactic mastectomy: A national Delphi consensus study. Psychooncology 2018; 27:2349-2356. [PMID: 29966172 DOI: 10.1002/pon.4830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/18/2018] [Accepted: 06/21/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Risk-reducing mastectomies (RRM) and contralateral prophylactic mastectomies (CPM) are increasingly prevalent strategies to reduce breast cancer risk. Given the associated physical and emotional challenges, presurgical psychological assessment is frequently recommended for this population, yet limited research exists to guide this. This study aimed to reach a consensus on the most relevant content and format of a psychological consultation prior to RRM/CPM. METHODS A modified two-round online Delphi study was conducted Australia-wide. Expert participants (n = 25), including psychologists, surgeons, nurses, oncologists, genetic specialists, and researchers completed a round-one survey, informed by a literature review, previous qualitative study and expert clinicians' input. This required participants to rate their agreement with 36 statements regarding potential content of a psychological consultation and provide feedback on format/structure. A round-two survey comprised items that had not reached consensus and six new items suggested by participants. Parameters for statement consensus were set a priori at >75% agreement. RESULTS Expert participants indicated agreement with the majority of statements (39/42, 92.8%), endorsing that the assessment should include (1) patient understanding of the RRM/CPM procedure/cancer risk, (2) potential physical/emotional impact of surgery, (3) informed decision-making, and (4) past/current psychological issues (anxiety and body image). A provisional assessment template and user manual is provided. CONCLUSIONS This research culminated in a consensus-based template to guide psychological assessment of women considering RRM/CPM. This enables health professionals to assess suitability for surgery and preempt challenges within a standardised framework. Future evaluation of the acceptability and effectiveness of the template in clinical settings is warranted.
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Affiliation(s)
- Lucy Braude
- School of Psychology, The University of Sydney, Camperdown, NSW, Australia
| | - Laura Kirsten
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Camperdown, NSW, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Camperdown, NSW, Australia.,Nepean Cancer Care Centre, Sydney West Cancer Network, Kingswood, NSW, Australia
| | - Jemma Gilchrist
- Mind My Health Clinical Psychology, Norwest Private Hospital, NSW, Australia
| | - Ilona Juraskova
- School of Psychology, The University of Sydney, Camperdown, NSW, Australia.,Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Camperdown, NSW, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Camperdown, NSW, Australia
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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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Carbine NE, Lostumbo L, Wallace J, Ko H. Risk-reducing mastectomy for the prevention of primary breast cancer. Cochrane Database Syst Rev 2018; 4:CD002748. [PMID: 29620792 PMCID: PMC6494635 DOI: 10.1002/14651858.cd002748.pub4] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010. OBJECTIVES (i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH METHODS For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English. SELECTION CRITERIA Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer. DATA COLLECTION AND ANALYSIS At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias. MAIN RESULTS All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM. AUTHORS' CONCLUSIONS While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.
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Affiliation(s)
- Nora E Carbine
- Georgetown University Lombardi Cancer CenterTranslational Breast Cancer Research Consortium (TBCRC)WashingtonD.C.USA20007
| | | | | | - Henry Ko
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation Building92‐94 Parramatta Rd.,CamperdownNSWAustralia2050
- Academic Medicine Research Institute, Duke‐NUS Graduate Medical SchoolCentre for Health Services Research, SingHealthSingaporeSingapore169857
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Greener JR, Bass SB, Lepore SJ. Contralateral prophylactic mastectomy: A qualitative approach to exploring the decision making process. J Psychosoc Oncol 2018; 36:145-158. [DOI: 10.1080/07347332.2017.1395940] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Judith R. Greener
- Department of Social and Behavioral Sciences, Temple University, College of Public Health, Philadelphia, PA, USA
| | - Sarah Bauerle Bass
- Department of Social and Behavioral Sciences, Associate Professor of Public Health, Director, Risk Communication Laboratory, Temple University, College of Public Health, Philadelphia, PA, USA
| | - Stephen J. Lepore
- Department of Social and Behavioral Sciences, Professor and Chair, Temple University, College of Public Health, Philadelphia, PA, USA
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38
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Braude L, Kirsten L, Gilchrist J, Juraskova I. A systematic review of women's satisfaction and regret following risk-reducing mastectomy. PATIENT EDUCATION AND COUNSELING 2017; 100:2182-2189. [PMID: 28732648 DOI: 10.1016/j.pec.2017.06.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE A systematic review of quantitative and qualitative studies, to describe patient satisfaction and regret associated with risk-reducing mastectomies (RRM), and the patient-reported factors associated with these among women at high risk of developing breast cancer. METHODS Studies were identified using Medline, CINAHL, Embase and PsycInfo databases (1995-2016). Data were extracted and crosschecked for accuracy. Article quality was assessed using standardised criteria. RESULTS Of the 1657 unique articles identified, 30 studies met the inclusion criteria (n=23 quantitative studies, n=3 qualitative studies, n=4 mixed-method studies). Studies included were cross-sectional (n=23) or retrospective (n=7). General satisfaction with RRM, decision satisfaction and aesthetic satisfaction were generally high, although some women expressed regret around their decision and dissatisfaction with their appearance. Factors associated with both patient satisfaction and regret included: post-operative complications, body image changes, psychological distress and perceived inadequacy of information. CONCLUSION While satisfaction with RRM was generally high, some women had regrets and expressed dissatisfaction. Future research is needed to further explore RRM, and to investigate current satisfaction trends given the ongoing improvements to surgical and clinical practice. PRACTICE IMPLICATIONS Offering pre-operative preparation, decisional support and continuous psychological input may help to facilitate satisfaction with this complex procedure.
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Affiliation(s)
- Lucy Braude
- School of Psychology, The University of Sydney, Sydney, Australia.
| | - Laura Kirsten
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, The University of Sydney, Sydney, Australia; Nepean Cancer Care Centre, Sydney West Cancer Network, Sydney, Australia
| | | | - Ilona Juraskova
- School of Psychology, The University of Sydney, Sydney, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of Psychology, The University of Sydney, Sydney, Australia
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Ward EP, Unkart JT, Bryant A, Murphy J, Blair SL. Influence of Distance to Hospital and Insurance Status on the Rates of Contralateral Prophylactic Mastectomy, a National Cancer Data Base study. Ann Surg Oncol 2017; 24:3038-3047. [PMID: 28766225 DOI: 10.1245/s10434-017-5985-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 01/09/2023]
Abstract
INTRODUCTION We evaluated the impact of travel distance and insurance status on contralateral prophylactic mastectomy (CPM) rates in breast cancer. METHODS We queried the National Cancer Data Base (NCDB) for women >18 years of age with a nonmetastatic primary breast cancer of ductal, lobular, or mixed histology. Patient- and facility-specific CPM rates were calculated based on insurance, race, and distance to treatment center. Standard univariable and multivariable regression analysis was performed. RESULTS Overall, the CPM rate was 6.5% for the 864,105 patients identified. Most patients traveled <20 miles to a treatment center (79.5%) and had private insurance or Medicare (58.3 and 33.4%, respectively). In general, younger, White, non-Hispanic, and privately insured patients residing further from a treatment center was associated with increased rates of CPM. However, distance to the treatment center and insurance type had a greater absolute impact on rates of CPM for Black and Hispanic patients. Absolute CPM rate increases for patients >100 miles from a treatment center compared with those <20 miles from a treatment center were observed to be greater for Black and Hispanic patients (3.5 and 3.9%, respectively) compared with White and non-Hispanic patients (2.5 and 2.6%). Additionally, further patient travel distance was associated with higher treatment center-specific CPM rates. CONCLUSION Increased travel distance is independently associated with increased rates of CPM for all patients and increased facility-specific rates of CPM. Black and Hispanic patients were found to be more vulnerable to the impact of travel distance and insurance status on rates of CPM.
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Affiliation(s)
- Erin P Ward
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Alex Bryant
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - James Murphy
- Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Sarah L Blair
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA.
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Miller ME, Muhsen S, Olcese C, Patil S, Morrow M, Van Zee KJ. Contralateral Breast Cancer Risk in Women with Ductal Carcinoma In Situ: Is it High Enough to Justify Bilateral Mastectomy? Ann Surg Oncol 2017; 24:2889-2897. [PMID: 28766208 DOI: 10.1245/s10434-017-5931-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Women with ductal carcinoma in situ (DCIS) are increasingly choosing bilateral mastectomy. We sought to quantify rates of contralateral breast cancer (CBC) and ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) for DCIS, and to compare risk factors for CBC and IBTR. METHODS From 1978 to 2011, DCIS patients undergoing BCS with a contralateral breast at risk were identified from a prospectively maintained database. The association of clinicopathologic and treatment factors with CBC and IBTR were evaluated using Kaplan-Meier analysis, multivariable Cox regression, and competing risk regression (CRR). RESULTS Of 2759 patients identified, 151 developed CBC and 344 developed IBTR. Five- and 10-year Kaplan-Meier CBC rates were 3.2 and 6.4%. Overall, 10-year IBTR rates were 2.5-fold higher than CBC rates, and, without radiation, 4-fold higher. On CRR, 5- and 10-year rates were 2.9 and 5.8% for CBC, and 7.8 and 14.5% for IBTR. CBC risk and invasive CBC risk were not significantly associated with age, family history, presentation, nuclear grade, year of surgery, or radiation. By multivariable Cox regression, endocrine therapy was associated with lower CBC risk (hazard ratio 0.57, p = 0.03). Ten-year risk of subsequent CBC in the subset of patients who developed IBTR was similar to the cohort as a whole (8.1 vs. 6.4%). CONCLUSIONS CBC rates were low across all groups, including those who experienced IBTR. CBC was not associated with factors that increase IBTR risk. While factors associated with IBTR risk are important in decision making regarding management of the index DCIS, they are not an indication for contralateral prophylactic mastectomy.
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Affiliation(s)
- Megan E Miller
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shirin Muhsen
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, 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.,Weill Medical College at Cornell University, 300 East 66th Street, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Weill Medical College at Cornell University, 300 East 66th Street, New York, NY, USA.
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Collins K, Gee M, Clack A, Wyld L. The psychosocial impact of contralateral risk reducing mastectomy (CRRM) on women: A rapid review. Psychooncology 2017; 27:43-52. [PMID: 28453892 DOI: 10.1002/pon.4448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES For women who have been diagnosed with unilateral breast cancer, there is an increasing trend for them to request removal of the contralateral healthy breast, the so-called contralateral risk reducing mastectomy (CRRM). The current literature is only just beginning to identify patient-reported reasons for undergoing CRRM and associated patient-reported outcomes. It is also unclear whether women at moderate/high risk of developing a subsequent primary contralateral breast cancer report similar outcomes to those considered to be at low/average risk. This lack of knowledge provides the rationale for this review. METHODS A rapid review methodology was undertaken to identify and explore the published research literature focused on the longer term (>5 y) psychosocial impacts on women who undergo CRRM. RESULTS Fifteen studies were identified. No UK studies were identified. High satisfaction and psychosocial well-being were consistently reported across all studies. Reducing the risk of a subsequent contralateral breast cancer and therefore reducing cancer-related anxiety, and satisfaction with cosmesis, were key themes running across all studies explaining satisfaction. Dissatisfaction was associated with adverse effects such as poor cosmesis, body image changes, femininity, sexual relationships, reoperations for acute and longer term complications, and reconstructive problems. CONCLUSIONS Satisfaction and psychological well-being following CRRM was consistently high across all studies. However, the findings suggest women need to be more fully informed of the risks and benefits of CRRM and/or immediate/delayed reconstruction to support informed decision making.
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Affiliation(s)
- Karen Collins
- Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Melanie Gee
- Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Anna Clack
- Centre for Health and Social Care Research, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Lynda Wyld
- Academic Unit of Surgical Oncology, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
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Falco G, Rocco N, Bordoni D, Marano L, Accurso A, Buccelli C, Di Lorenzo P, Capasso E, Policino F, Niola M, Ferrari G. Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients. Open Med (Wars) 2016; 11:238-241. [PMID: 28352801 PMCID: PMC5329834 DOI: 10.1515/med-2016-0047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/18/2016] [Indexed: 01/02/2023] Open
Abstract
The use of contralateral risk reducing mastectomy (CRRM) is indicated in women affected by breast cancer, who are at high risk of developing a contralateral breast cancer, particularly women with genetic mutation of BRCA1, BRCA2 and P53. However we should consider that the genes described above account for only 20-30% of the excess familiar risk. What is contralaterally indicated when genetic assessment results negative for mutation in a young patient with unilateral breast cancer? Is it ethically correct to remove a contralateral "healthy" breast? CRRM rates continue to rise all over the world although CRRM seems not to improve overall survival in women with unilateral sporadic breast cancer. The decision to pursue CRRM as part of treatment in women who have a low-to-moderate risk of developing a secondary cancer in the contralateral breast should consider both breast cancer individual-features and patients preferences, but should be not supported by the surgeon and avoided as first approach with the exception of women highly worried about cancer. Prospective studies are needed to identify cohorts of patients most likely to benefit from CRRM.
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Affiliation(s)
- Giuseppe Falco
- Breast Surgery Unit Arcispedale-IRCCS Santa Maria Nuova, Reggio Emilia, Italy
| | - Nicola Rocco
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Napoli, Italy
| | - Daniele Bordoni
- Department of Senology, “Santa Maria della Mi-sericordia” Hospital, Urbino, Italy
| | - Luigi Marano
- Robotic Surgery Unit, “San Matteo degli Infermi” Hospital - ASL Umbria 2, 06049, Spoleto (PG), Italy
| | - Antonello Accurso
- Department of Gastroenterology, Endocrinology and Surgery, Breast Unit, AOU “Federico II”, Naples, Italy
| | - Claudio Buccelli
- Department of Advanced Biomedical Sciences, Naples, Italy, University “Federico II” of Naples, via S. Pan-sini,5, 80131 Naples, Italy
| | - Pierpaolo Di Lorenzo
- Department of Advanced Biomedical Sciences, Naples, Italy, University “Federico II” of Naples, via S. Pan-sini,5, 80131 Naples, Italy
| | - Emanuele Capasso
- Department of Advanced Biomedical Sciences, Naples, Italy, University “Federico II” of Naples, via S. Pan-sini,5, 80131 Naples, Italy
| | - Fabio Policino
- Department of Advanced Biomedical Sciences, Naples, Italy, University “Federico II” of Naples, via S. Pan-sini,5, 80131 Naples, Italy
| | - Massimo Niola
- Department of Advanced Biomedical Sciences, Naples, Italy, University “Federico II” of Naples, via S. Pan-sini,5, 80131 Naples, Italy
| | - Guglielmo Ferrari
- Breast Surgery Unit Arcispedale-IRCCS Santa Maria Nuova, Reggio Emilia, Italy
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