Lara C. Pullen, PhD

October 10, 2012

October 10, 2012 (Chicago, Illinois) — Most prophylactic surgeries performed in the United States are self-pay and occur in the South and Midwest, researchers reported here at the American College of Surgeons 98th Annual Clinical Congress.

As more and more women are turning to prophylactic surgery, surgeons are facing issues of access, awareness, and the quantification of benefits, according to study author Jessica Ryan, MD, from the Tufts University School of Medicine in Boston, Massachusetts.

Dr. Ryan noted that a significant increase in the awareness and diagnosis of genetic susceptibility has led to an increasing trend in prophylactic surgery. The study by her team was designed to identify the characteristics of patients who chose prophylactic surgery in such a setting.

Dr. Ryan and colleagues analyzed data from the Nationwide Inpatient Sample from 2004 to 2009. They reviewed hospitalizations, including those for genetic susceptibility and prophylactic procedures, such as mastectomies.

During the study period, there was a 16-fold increase in hospitalizations associated with genetic susceptibility, from 188 in 2004 to 3102 in 2009 (P < .001). Prophylactic surgery increased more than 2-fold over the same period (from 4450 to 9793; P < .001).

The most common genetic susceptibilities were breast cancer (67.1%) and ovarian cancer (23.0%). Correspondingly, the most common prophylactic procedures were mastectomy (64.3%) and oophorectomy (40.0%).

An analysis of patient demographics found that 86.0% of patients were white and 98.0% were female. Most (81.4%) of the women who underwent prophylactic surgery had private insurance, and 43.6% were from the highest median income quartile.

Most of the hospitals in which the prophylactic surgeries were performed were small (44.5%), nonteaching (82.4%), and urban (60.1%). They also tended to be located in the South (39.9%) or Midwest (28.6%).

High Rates of Self-Pay

On multivariate logistic regression analysis, self-pay (odds ratio [OR], 2.243; P = .003) and residing in the South (OR, 1.136; P = .041) were statistically associated with prophylactic surgery.

Dr. Ryan was surprised to find that women older than 50 years were more likely to turn to prophylactic surgery than women of child-bearing age.

David R. Byrd, MD, FACS, from the Seattle Cancer Care Alliance in Washington, who moderated the session, called the study topic "very timely," and noted that "this type of presentation brings up all types of important issues.... I have patients coming into my clinic now with their DNA tests already done.... All of us as clinicians need to be thinking about how we are going to respond."

Personalized genome-wide tests are becoming increasingly available and aggressive surgery is becoming more common. Although surgery can prevent cancer occurrence and recurrence, it also represents a potential harm to patients and health systems, according to experts. A better understanding of the socioeconomic and regional variations related to prophylactic surgery might aid in clinical practice and patient counseling.

For example, previous studies have shown that patients carrying the BRCA mutation who receive genetic counseling are likely to choose prophylactic surgery. Younger, more educated women who have a family history of breast cancer are also more likely to opt for prophylactic surgery.

In contrast, women who decline prophylactic mastectomy tend to have more confidence in screening as a risk-management plan and are more likely to have a fatalistic view about the development of breast cancer. Overall, cancer worry and anxiety was found to be the greatest predictor of prophylactic surgery.

Dr. Ryan and Dr. Byrd have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 98th Annual Clinical Congress: Abstract NP2012-23444. Presented October 3, 2012.