Surgeon's Input Influences Decision for CPM in Breast Cancer

Roxanne Nelson, BSN, RN

December 21, 2016

Rates of contralateral prophylactic mastectomy (CPM) have been rising among women with early breast cancer, even when there is no clinical indication for it. However, rates of CPM were much lower when patients reported that their surgeon recommended against it, according to the findings of a new survey.

The survey authors found strong patient interest in CPM and substantial use of this surgical procedure, even by patients who were unlikely to derive any benefit.

Only 38% of respondents were aware that CPM does not improve survival for all patients with breast cancer.

Seventeen percent of the cohort underwent CPM, but among those who reported that a surgeon had recommended against the procedure, only 1.9% had the surgery.

In contrast, 19% of patients who had received no recommendation for or against CPM from a surgeon underwent CPM.

The survey results are published online December 21 in JAMA Surgery.

"Rates of CPM are substantial even in a diverse, population-based sample, and patient knowledge in this context is poor," write the authors, led by Reshma Jagsi, MD, DPhil, from the University of Michigan, Ann Arbor. "When they do not perceive a surgeon's recommendation against it, even patients without a high genetic risk for a second primary breast cancer choose CPM at an alarmingly high rate (nearly 1 in 5)."

But these can be very difficult conversations, Dr Jagsi explained. "Women are often very understandably frightened after receiving a breast cancer diagnosis and highly motivated to do everything possible."

"It may not necessarily be intuitive to a patient why removing both breasts is not expected to improve survival, so explaining this can require a great deal of time and effort," Dr Jagsi told Medscape Medical News. "This is further complicated by the fact that some surgeons may worry that if they try to guide patients towards less aggressive approaches, they may alienate those patients or seem like they aren't being respectful of the patient's perspective."

He added that "as physicians, we place great value in respecting our patients' preferences, and it can be quite challenging to strike the right balance when trying to inform and guide patients at such a stressful and vulnerable time."

Rising Rates Without Benefit

The increase in CPM in the United States has been well documented, but so has the lack of significant survival benefit from the procedure. One 2014 paper reported that across several subgroups of women with early-stage disease, there was less than a 1% survival benefit after 20 years for all groups.

Other research has cited that mistaken beliefs about the effectiveness of mastectomy and unfounded fears about the risks for contralateral disease, especially among younger women, are driving the uptick in CPM procedures.

Earlier this year, the American Society of Breast Surgeons issued a consensus statement stating that women diagnosed with breast cancer who are at average risk should be discouraged from undergoing CPM because most will obtain no oncologic benefit.

"Peace of Mind" and Other Reasons

In the current study, Dr Jagsi and colleagues investigated patient motivations, knowledge, and decisions, as well as the effect of surgeon recommendations, on the decision to undergo CPM after a diagnosis of early breast cancer.

Of the 2402 respondents included in the final analysis, 428 (24.9%) patients had stage 0 disease (ductal carcinoma in situ), 1258 (46.9%) had stage I disease, and 611 (24.7%) had stage II disease.

About a quarter of the women (n = 555 [23.8%]) reported having a first-degree family member with breast cancer, and nearly two thirds (n = 1569 [65.5%]) had neither a known deleterious mutation nor a high risk for a genetic mutation.

Most of the women (n = 1466 women [61.6%]) underwent breast conservation surgery, while 508 (21.2%) had a unilateral mastectomy and 428 (17.3%) received a bilateral mastectomy with CPM.

Of the women who had considered CPM, 23.8% believed it improved survival and 38.1% reported that they didn't know.

But of the women who did undergo CPM, 158 (37.3%) believed it that it would affect survival.

Aside from a survival benefit, the survey respondents cited several reasons why they decided to undergo CPM. Most (96.3%) reported that peace of mind was very or quite important in motivating them to make that decision; other reasons included age, family history, and a desire to have reconstruction for symmetry.

Smaller numbers of patients cited BRCA mutation status or a desire to alter their breast size.

Patient characteristics and demographics also seemed to play a role in choosing CPM. For example, black patients were significantly less likely to have CPM than white patients, and those with a higher education were more likely to undergo the procedure.

Medicaid patients were significantly less likely to receive CPM compared with patients who were privately insured.

Interestingly, the authors note, patients who were known to be carriers of a deleterious mutation or at high risk for genetic mutations were only marginally more likely to receive CPM. This difference did not achieve statistical significance (OR, 1.33; P = .005).

Overcome Fear and Misperception

In an accompanying editorial, Oluwadamilola M. Fayanju, MD, MA, MPHS, and E. Shelley Hwang, MD, both from Duke University, Durham, North Carolina, note that the rising rate of CPM in the United States is a source of increasing concern for breast oncologists.

But even though CPM is not associated with improved survival, "it reduces the risk of contralateral breast cancer, and the significance of this fact to some patients should not be minimized," they write.

"As we move toward an ever-more personalized, patient-centered approach to care, we must thoughtfully weigh the balance between respecting patients' preferences and leaving them with the long-term consequences associated with an 'unnecessary' operation," the editorialists point out.

As discussed in the study, surgeon recommendation plays an important part in decisions concerning CPM. But the editorialists wonder what is the "surgeon's responsibility, and how does he or she educate without condescension and empower without misdirection?"

Dr Fayanju and Dr Hwang conclude that it is clear that not all patients should be discouraged from undergoing CPM. That said, "surgeons must be engaged in patients' decision-making and remain invested in providing accurate information about the risks of CPM," they write.

And while patients need to be supported to make their own decisions, "the medical community must continue to do our part to educate patients on the negligible benefits of this procedure and help to overcome some of the fear and misperception that often drive this decision."

This study was supported by the National Cancer Institute of the National Institutes of Health under award P01CA163233 to the University of Michigan. Dr Jagsi has disclosed no relevant financial relationships; coauthor Dr Kurian has received research funding for work performed outside of the present study from Myriad Genetics, Invitae, Ambry Genetics, GeneDx, and Genomic Health. The editorialists have disclosed no relevant financial relationships.

JAMA Surg. Published online December 21, 2016. Abstract, Editorial

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