Worry Spurs Double Mastectomy in the US

Nick Mulcahy

November 27, 2012

Ninety percent of women with early-stage breast cancer who received contralateral prophylactic mastectomy were "very worried" about recurrence, according to a survey of women in American cancer registries.

The worry seemed to influence decision-making, because about 80% of the women who had the double surgery were, in fact, at "very low risk for contralateral disease," said lead researcher Sarah T. Hawley, PhD, MPH, who is associate professor of general medicine at University of Michigan in Ann Arbor.

"Worry about recurrence had a strong influence on receipt of contralateral prophylactic mastectomy, although this procedure has not been associated with reducing recurrence risk," she said.

Dr. Hawley spoke at a presscast held in advance of the inaugural Quality Care Symposium, which will take place November 30 to December 1 in San Diego, California.

The researchers collected data on women with breast cancer from Surveillance, Epidemiology, and End Results (SEER) registries in Detroit, Michigan and Los Angeles, California from 2005 to 2007. Of the 1446 women they surveyed, 101 (7.4%) underwent a contralateral prophylactic mastectomy.

However, only about one fifth of these 101 recipients met the clinical guideline recommendation for contralateral prophylactic mastectomy (a strong family history and/or positive genetic test result).

About four fifths did not have either of these clinical indications, which means that most of the contralateral prophylactic mastectomy patients were likely overtreated.

In the general population of women diagnosed with breast cancer, the risk of developing a new cancer in the unaffected breast is less than 1%, according to the American Society of Clinical Oncology.

In women with a family history of breast cancer, the risk of having a contralateral recurrence is higher, at 10% to 15%, said Jyoti Patel, MD, from Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois, who moderated the presscast. If a woman also has a BRCA1 or BRCA2 mutation, the risk increases still more, she explained.

Dr. Patel noted that many women are worried and fearful not only about recurrence, but also about lifelong surveillance in their unaffected breast.

Misconception about recurrence risk reduction could play a role in some women's decision about surgery, Dr. Hawley added.

"Our findings suggest that some women made the decision based on their misconception about the ability of contralateral prophylactic mastectomy to reduce the risk of local recurrence of cancer," she said in a press statement. "In everyday practice, this means that physicians need to understand the strong impact of worry about cancer recurrence in patient decision making, and may need to do a better job of educating and reassuring women about their true risks of cancer recurrence and of developing a new cancer."

Correlates of Surgery Choice

Dr. Hawley and colleagues initially surveyed 2245 women with newly diagnosed breast cancer, and resurveyed 1525 approximately 4 years later. The women received lumpectomy, unilateral mastectomy, or contralateral prophylactic mastectomy. For their study, the researchers used data from the 1446 women who had not had a recurrence by the time of the second survey.

They also looked at family history, genetic test results, and worry about recurrence to determine the degree to which they were correlated with contralateral prophylactic mastectomy.

Of the patients treated with some form of mastectomy, recipients of contralateral prophylactic mastectomy were 1.76 times more likely than recipients of unilateral mastectomy to have 1 first-degree relative with breast cancer and 4.40 times more likely to have 2 or more such relatives (P < .001).

Recipients of contralateral prophylactic mastectomy were 10.61 times more likely than recipients of unilateral mastectomy to have tested positive for a mutation (P < .001).

But worry also had a statistically significant association with choice of surgery. Recipients of contralateral prophylactic mastectomy were 2.2 times more likely than recipients of unilateral mastectomy to have a high level of worry about recurrence (P < .05).

2012 Quality Care Symposium. Abstract 26. To be presented November 30, 2012.