Doctor’s Recommendation Against Prophylactic Mastectomy Doesn’t Seem to Affect Satisfaction With Surgery Decision

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Some women who’ve been diagnosed with early-stage breast cancer in one breast choose to have that breast and the other healthy breast removed -- a double mastectomy. Removing the other healthy breast is called contralateral prophylactic mastectomy.

The healthy breast usually is removed because of an understandable fear that a new, second breast cancer might develop in that breast. More and more women who’ve been diagnosed are opting for contralateral prophylactic mastectomy -- in the late 1990s, between 4% and 6% of women who were having mastectomy decided to have the other healthy breast removed. A 2016 study found that rates of contralateral prophylactic mastectomy more than tripled from 2002 to 2012.

Because of this increase, doctors wondered what women thought if their surgeons recommended against contralateral prophylactic mastectomy. Would they seek out a second opinion? Would they be less satisfied with their decision about surgery?

A study suggests that few women seek a second opinion when their surgeons recommend against contralateral prophylactic mastectomy and most are happy with their surgery decision.

The research was published online on April 5, 2017 by JAMA Surgery. Read “Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer.”

To do the study, the researchers identified 3,880 women ages 20 to 79 diagnosed with stage 0 to stage II breast cancer between 2013 and 2014 who lived in Georgia and California.

The researchers found the women by looking in the SEER database, a large registry of cancer cases from throughout the United States maintained by the National Institutes of Health.

After excluding women who didn’t want to participate and women who were diagnosed with breast cancer in both breasts, the researchers surveyed 1,140 women for the study.

The surveys were sent about 2 months after the women had breast cancer surgery and asked about:

  • how strongly the women considered contralateral prophylactic mastectomy
  • whether the first surgeon the women consulted recommended having contralateral prophylactic mastectomy
  • whether or not the surgeon discussed the benefits and risks of contralateral prophylactic mastectomy, including survival, recurrence, diagnosis of a new cancer in the opposite breast, cosmetic outcomes, and recovery from surgery
  • family history of cancer
  • satisfaction with surgery decision
  • whether or not the woman sought a second opinion on the type of breast cancer surgery she should have
  • whether or not the women had breast cancer surgery done by a second surgeon

The characteristics of the women in the study were:

  • 56.1% were younger than 60
  • 41.8% were college graduates
  • 53.7% were white, 16.0% were black, 18.4% were Hispanic, and 8.1% were Asian
  • 63.9% were married
  • 65.6% were working
  • 60.1% were considered at high risk for recurrence, based on family history and/or genetic testing
  • 16.1% were diagnosed with stage 0 disease, 55.3% were diagnosed with stage I disease, and 28.6% were diagnosed with stage II disease

Overall, more than half the women (57.5%) strongly or very strongly considered contralateral prophylactic mastectomy.

Ultimately, a little more than one-third of the women had contralateral prophylactic mastectomy:

  • 40.5% had lumpectomy
  • 22% had single mastectomy (41.4% had reconstruction)
  • 38.2% had contralateral prophylactic mastectomy (76.7% had reconstruction)

When the researchers looked at how the women described their first surgeon’s recommendations, they found that about one-quarter said their first surgeon recommended against contralateral prophylactic mastectomy and most surgeons discussed the procedure:

  • 26.7% of the women said their first surgeon was against contralateral prophylactic mastectomy
  • 67.3% said their first surgeon was not against contralateral prophylactic mastectomy
  • 63.1% of the women said their first surgeon discussed contralateral prophylactic mastectomy with them
  • 30.1% said their first surgeon didn’t discuss contralateral prophylactic mastectomy with them

Still, only 7.6% of the women were dissatisfied with their surgery decision. While this number was small, dissatisfaction with the surgery decision was higher for women who said their surgeon recommended against contralateral prophylactic mastectomy or didn’t discuss contralateral prophylactic mastectomy with them.

About 20% of the women sought out a second opinion from another surgeon, and 9.8% of the women had surgery done by the second surgeon.

"We hypothesized that patients whose first surgeons recommended against contralateral prophylactic mastectomy might report less satisfaction and might be more likely to seek second opinions and pursue surgery by a second surgeon," said the study's lead author Steven J. Katz, M.D., M.P.H., professor of medicine and of health management and policy at the University of Michigan. "But in this study, an initial recommendation against contralateral prophylactic mastectomy had little impact on overall satisfaction with treatment or on decisions to pursue or act on a second opinion.

"The increased attention to and preference for contralateral prophylactic mastectomy among patients for whom it is not a clinical imperative is a relatively recent phenomenon," Katz added. "It's one of many considerations on the minds of patients we know are understandably anxious and who may feel they need to make treatment decisions quickly after diagnosis."

He said that doctors are looking for guidance on how to address patients' concerns and respect their wishes without exposing them to more extensive treatment than medically called for or losing them to another surgeon.

"About 95% of breast cancer patients are treated by the first surgeon they see," said Katz. "It's so important in those initial consultations that the patient and the surgeon feel free to discuss all of the options and work together to determine the best path forward."

When you’re first diagnosed with breast cancer, fears about the future can affect how you make decisions. This is especially true for women who have an abnormal breast cancer gene or who have watched a mother or sister be diagnosed with breast cancer. You have to make a number of decisions at a very emotional time when it can be hard to absorb and understand all the new information you’re being given.

At Breastancer.org, we support every woman’s right to make treatment decisions based on the characteristics of the cancer she’s been diagnosed with, her medical history, her risk of recurrence or a new breast cancer, and her personal preferences. But it’s very important to make sure you understand all the pros and cons of any treatment or procedure you’re considering, including how the treatment or procedure may affect your reconstruction options and if the treatment is likely to make you live longer.

If you’ve been diagnosed with early-stage breast cancer, ask your doctor about ALL of your treatment and risk reduction options. Contralateral prophylactic mastectomy is only one of these options and is an aggressive step. While it may be the right decision for you, give yourself the time you need to consider the decision carefully. It’s a good idea to talk to your doctor about how the details in your pathology report may affect your future risk. You want to be sure that your decisions are based on your actual risk of recurrence or a new cancer. Make sure you understand the benefits and risks of all your options. Together, you and your doctor can make the choices that are best for you and your unique situation.



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