Research Brief, Addressing Peace of Mind in Contralateral Prophylactic Mastectomy for Breast Cancer

The use of prophylactic mastectomy in the U.S. among patients with invasive breast cancer in only one breast has increased dramatically in the past two decades. Although removal of the noncancerous breast has been shown to reduce the risk for developing cancer in that breast, there is conflicting evidence on whether or not the practice actually reduces breast cancer mortality or overall death.

A recent Viewpoint in the Journal of the American Medical Association states that the sense of urgency for cancer treatment and concern that any delay could worsen prognosis, coupled with a general belief that “bigger is better” when it comes to surgery, leaves patients at risk for unnecessary harm and overtreatment. The authors cite a large study of 107,106 women between 1998 and 2003 who were diagnosed with breast cancer in only one breast. The study found that for those at average risk of developing a second primary breast cancer, removal of the unaffected breast for preventive reasons was not a benefit in terms of improving distant disease-free survival. For this reason, current protocols only recommend consideration of the removal of the unaffected breast for people at high risk of developing a second primary breast cancer.

Despite evidence to suggest that removal of both breasts increases risk for complications without the congruent benefit of improved long-term survival, many patients still seem to opt for the more aggressive operations. The researchers argue patients tend to underestimate the adverse effects of the more aggressive surgical treatment while overestimating both their risk of developing a second primary cancer and the benefits of removing the unaffected breast.

To address these issues, the authors conclude that (1) surgeons themselves must ensure that patients fully understand the risks and benefits of more aggressive surgical treatment; (2) that patients should take more time to think about the benefits and risks of such treatments while also considering how emotional reactions may favor aggressive approaches; and (3) that the medical institution must address incentives within the system that foster overtreatment in cancer.

Source: Steven J. Katz, MD, MPH and Monica Morrow, MD. 2013. ”Contralateral Prophylactic Mastectomy for Breast Cancer: Addressing Peace of Mind,” JAMA [Aug;310(8):793-4].

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