Expert Discusses Recommending Against Prophylactic Mastectomy

Steven J. Katz, MD

Desire to undergo a contralateral prophylactic mastectomy (CPM) has been rising in patients diagnosed with breast cancer in recent years. CPM is discouraged for patients without an elevated risk for a second primary breast cancer, as per surgical guidelines.

A population-based survey was conducted to examine the association between patient report of surgical recommendation against CPM and to what extent it was discussed with the surgeon. Three outcomes were considered: patient satisfaction with surgery decisions, receipt of a second opinion, and receipt of surgery by a second surgeon.

“Surgeons have been concerned about the rise in the use of this procedure, which is quite morbid—the removal of both breasts. They are not enthusiastic about performing this procedure in the tens of thousands of women who will receive it this year, and they are concerned about how to have this discussion with patients,” said lead author Steven J. Katz, MD.

Katz says that surgical recommendation against CPM did not seem to push patients to seek a second opinion or to switch surgeons. Although, findings did show that patients were less satisfied with surgical decision if the surgeon who recommended against CPM did not have a substantive discussion about it.

OncLive: Could you provide some background on the rationale behind this study?

In an interview with OncLive, Katz, professor of medicine and health management and policy at the University of Michigan, discussed his study of patient reaction to surgeon recommendations about CPM.Katz: CPM for women with early-stage breast cancer is a major issue that has evolved over the past 5 to 7 years and the number of the women undergoing this most extensive surgical treatment has increased rather dramatically. This is probably related to more attention given to the procedure from famous people who got it, and with more women getting CPM in the community—newly diagnosed patients know of a daughter or mother or friend who have had it and are very happy with the fact that they feel that they are completely free of any future possibility of having the caner. The problem with this mindset is that many women getting CPM are at average risk for a second primary cancer. The risk of developing a secondary breast cancer is so low, given all of the other reasons, that CPM in average-risk women does not confer any benefit with regard to survival or even distant recurrence. Additionally, reconstructive surgery means more days lost at work and long-term quality-of-life issues related to not having the natural breast.

The study that we did was a large survey of patients, shortly after diagnosis, in Georgia and Los Angeles county, and we asked what their surgeons recommended and what their reaction was along 3 lines: did they get a second opinion, did they go to a different surgeon to get the operation if their first surgeon recommended against it, or did the suggestion affect their satisfaction with overall surgical decision making.

What we found was pretty reassuring—about one-third of women reported that their surgeons recommended against CPM. That report was not associated with a second opinion or losing the patient to a second surgeon. There was a little bit of dissatisfaction—women were more dissatisfied with their overall surgical decision, not based on the recommendation alone, but whether that was well discussed or not. If the recommendation was not well discussed, those patients were somewhat more dissatisfied with the overall surgical decision.

The conclusion of the paper was that there was a substantial amount of patients reporting that their surgeons are recommending against this most aggressive treatment, that it doesn't seem to be motivating patients to go to another surgeon, and that dissatisfaction with decision-making seems to be tied with the adequacy of discussion over exactly what recommendation is made. The pushback against this surgery does not seem to be causing a great discourse in the clinical encounter.

How do you feel these findings will impact surgical decisions moving forward?

Moving forward, we need to have these discussions and those discussions need to be a little more proactive then they have been in the past. We did not have to worry about this 7 years ago before women were much more interested than they are now.I think that this is a very important issue. What we have learned in our research is that patients often desire the most extensive treatment, whether it is surgery or medicine. I think that surgeons in the nation are concerned about this, as well as how to manage this extensive treatment with their patients. Overtreatment needs to be addressed in patients who want to undergo a more extensive treatment than is necessary, because that will actually bring more harm than good.

What would you suggest surgeons focus on to help guide patients in a more proactive way?

The rise in desire for CPM is a good example of surgeons recalibrating, revisiting how they want to approach an issue. One of the most important things is to talk to women about this procedure, and what the marginal benefit is to them, and try to help them resist their fear of disease and treatment that might be motivating them to seek everything that they can possibly get now, so that they can get home to their families. The problem is, getting everything now can actually result in more harm than good because most patients do not need everything. CPM, in most surgeon's eyes, is overtreatment, and they have to talk to their patients more so their patients understand this natural tendency to desire more extensive treatment.I would suggest a couple things—many patients increasingly rely on their doctors because this type of information is so complex. Let that happen, it is okay, let patients seek out navigation by the surgeons and medical oncologists. Also, decision making of this nature is not a surgical emergency, there is time. When there is not adequate time to talk, the immediate reaction is “take them away and get me home.” We want to resist this immediate reaction by spending time with patients, slowing the process down—let them ponder what the surgeons actually have to say about the pros and cons of this procedure.

I also recommend that patients ask their surgeons to summarize their recommendations and why, and audiotape it and listen to it a few times. Turn to your surgeon at the end of the meeting and say, “I’d to hear your recommendations against this surgery and why, and I’d like to record it on my phone.” And then patients can walk away and come back to that information. It is also good for patients to have someone in the room with them to clarify any questions because it is hard to ask questions when you are in the room alone right after diagnosis. Most women with breast cancer have someone in the room with them, and most women report that that person is taking notes for them—which is another good thing because that person is not going through the disease, and the notes can be much more unbiased and be more reflective about what can happen next.

Katz SJ, Janz NK, Abrahamse P, et al. Patient reactions to surgeon recommendations about contralateral prophylactic mastectomy for treatment of breast cancer [published online April 5, 2017]. JAMA Surg. doi:10.1001/jamasurg.2017.0458.