Rates of Preventive Mastectomy for Breast Cancer Influenced by Surgeon Attitudes

In light of rising rates of preventive mastectomies among women with breast cancer, a new study looks at whether patient and surgeon factors, including attitudes toward breast conservation, affect the odds of receiving this surgery.

Contralateral prophylactic mastectomy (CPM) occurs when a patient diagnosed with breast cancer undergoes a mastectomy on the other, non-affected breast to help prevent the future spread of cancer. Guidelines recommend it only when patients are at high risk of second primary breast cancers, but rates of the procedure have increased rapidly over the last decade, according to the study published in JAMA Surgery.

Researchers analyzed a sample of over 3300 women newly diagnosed with early-stage breast cancer and their oncology surgeons to determine whether patient and surgeon characteristics affect the likelihood of patients receiving CPM. The patient factors included age, risk of second cancer, and BRCA test results, while the surgeon variables included age, sex, years in practice, and their responses to scales indicating their tendency to favor initial breast conservation and their reluctance to perform CPM.

In a hypothetical case where a woman had no contraindications to breast conservation, physicians generally favored breast-conserving surgery over CPM; 96% said they would definitely not or probably not recommend CPM in this case, and a majority would probably or definitely recommend against it. The most commonly reported reasons for performing CPM if requested were for patient peace of mind, to avoid conflict with patients, and to improve cosmetic outcomes.

The researchers also found that responses to the 2 scales were not correlated, meaning that there were many physicians who scored high on the conservation scale and low on their reluctance to perform CPM, or vice versa.

At the patient level, both age and BRCA status were strong predictors of CPM, meaning younger women and BRCA-positive women were more likely to undergo the procedure. However, the surgeon factors explained more of the variability in the odds of CPM than the patient factors.

While a surgeon who scored the mean on both scales had an average CPM rate of 13%, the rate was strongly affected by variation in attitudes as measured through the scales. For instance, the rate of CPM was 34% among surgeons who least favored initial breast conversation and were least reluctant to perform CPM, whereas it was just 4% among those who most favored conservation and were most reluctant.

“Surgeon attitudes about the options for initial surgery and their reactions to patient requests for treatment influence whether a patient with similar attributes receives CPM,” the study authors concluded. “Our findings motivate the need to help surgeons address this growing clinical conundrum in the examination room.”

They recommended that surgeons receive more training and decision support tools to help them communicate better with patients about the risks and benefits of aggressive surgery as part of the breast cancer management plan.