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Many bilateral mastectomies done in women at low risk of contralateral cancer

JAMA Surgery
Reuters Health - 16/02/2021 - Many women undergo medically unnecessary contralateral prophylactic mastectomy, and reducing the rate of these procedures requires a "social change" involving patients and physicians, as well as cultural and systems-level transformations, a review article suggests.

"The risk of developing contralateral breast cancer may be less than what women perceive it to be," coauthor Dr. David Lim of Women's College Hospital in Toronto told Reuters Health by email. In a recently submitted study, he said, his team found that within 25 years of a breast cancer diagnosis, women had only a 10% risk, on average.

In women without a genetic variant, the average risk for contralateral cancer is 0.5% annually, with younger age at diagnosis associated with a greater cumulative lifetime risk, his team notes in JAMA Surgery.

Women who do benefit from a CPM, Dr. Lim added, "are BRCA carriers and possibly women who are diagnosed with their first breast cancer at a very young age and have a strong family history."

In average-risk women with unilateral in situ and invasive breast cancer, contralateral prophylactic mastectomy (CPM) rates increased from less than 2% in 1998 to 30% in 2012, according to a 2019 report in Breast Cancer Research and Treatment.

To investigate the reasons behind the increase, the team reviewed the literature for relevant studies from 1995 to June 2020. While acknowledging that the reasons "are multifactorial and complex," they identified the following:

- Increased diagnosis of bilateral cancers due to increased use of breast magnetic resonance imaging;

- Increased genetic testing identifying more women with breast cancer as BRCA 1 and BRCA2 carriers;

- Novel risk-assessment models identifying women at high risk of developing contralateral breast cancer;

- Fear of cancer recurrence and the desire to avoid a second round of treatment;

- Cancer-related distress that negatively impacts quality of life;

- Body image considerations and access to breast reconstruction; and

- Surgeon preference and the influence of social networks and media.

"As part of the physician-patient relationship, we recommend that surgeons explore the individual concerns of women and their reasons for wanting a preventive contralateral mastectomy. A team-based approach is desirable," the authors conclude.

"We need to explore further the issue of decision satisfaction or regret," Dr. Lim said. "The literature shows that many women who have bilateral mastectomies remain satisfied with their decision and would do it again, in spite of the lack of proven benefit on survival or quality of life. This level of decision satisfaction may empower other women who are considering bilateral mastectomy to go through with the procedure as well."

"Professional societies ask surgeons to explore women's motivations for bilateral surgery," he added. "However, what is actually discussed and how much time surgeons devote to the discussion is completely at the discretion of each individual surgeon. Additionally, surgeons are not explicitly taught how to conduct these types of discussions."

"Another JAMA Surgery report published on February 3 (https://bit.ly/2ZaCLZh) demonstrates that institutional culture may also play an important role," he noted. "Some institutions perform a significant number of bilateral mastectomies while others seem to refuse the procedure outright no matter what."

"We believe that the rising trend in bilateral mastectomies is not going to reverse anytime soon," he said.

Dr. Jessica Young, Surgical Oncologist at Roswell Park in Buffalo, New York, commented by email to Reuters Health, "This topic is quite complicated, and as the paper points out, the decision for CPM is likely multifactorial."

"The paper stated that 'it is unclear how the payer affects CPM rates,' but I would disagree. If CPM were not covered by insurance, I think that the rates would drop dramatically," she said. "However, I do agree that funding support for CPM is unlikely to change."

"These conversations about CPM take a lot of time, especially when a patient likely already has a strong predisposition to CPM," she said. "In the course of a busy surgical practice, it can be more difficult to have a thorough conversation than to go along with the preconceived desire."

"Changing the tide of CPM is going to be a slow change, but it can be realistically done," she added. "More quality-of-life studies will help give women a better evidence-based perspective when making their decisions. These studies can help us to better address the issue of anxiety surrounding diagnosis and fear of recurrence to help better treat the patient overall and help them through this traumatic time in whatever way is best for them."

SOURCE: https://bit.ly/2Zk85EQ JAMA Surgery, online February 10, 2021.

By Marilynn Larkin

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