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Author Notes:

Corresponding author: Dr. Jagsi, Department of Radiation Oncology, University of Michigan; UHB2C490, SPC 5010; 1500 East Medical Center Drive; Ann Arbor, MI 48109-5010; telephone (734) 936-7810; fax (734) 763-7370; rjagsi@med.umich.edu

Drs. Morrow and Katz contributed equally.

Reshma Jagsi and Kent Griffith had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

We acknowledge the outstanding work of our project staff (Mackenzie Crawford and Kiyana Perrino from the Georgia Cancer Registry; Jennifer Zelaya, Pamela Lee, Maria Gaeta, Virginia Parker, and Renee Bickerstaff-Magee from USC; Rebecca Morrison, Rachel Tocco, Alexandra Jeanpierre, Stefanie Goodell, and Rose Juhasz from the University of Michigan).

We acknowledge with gratitude our survey respondents.

Conflict of Interest: Allison W. Kurian has received research funding for work performed outside of the current study from Myriad Genetics, Invitae, Ambry Genetics, GeneDx, and Genomic Health.

The remaining authors have no conflict of interest to report.

Subjects:

Research Funding:

Research reported in this publication was supported by the National Cancer Institute (NCI) of the National Institutes of Health under award number P01CA163233 to the University of Michigan.

The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s (CDC) National Program of Cancer Registries, under cooperative agreement 5NU58DP003862-04/DP003862; the NCI’s Surveillance, Epidemiology and End Results Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California (USC), and contract HHSN261201000034C awarded to the Public Health Institute.

The collection of cancer incidence data in Georgia was supported by contract HHSN261201300015I, Task Order HHSN26100006 from the NCI and cooperative agreement 5NU58DP003875-04-00 from the CDC.

Keywords:

  • Age Factors
  • Aged
  • Breast Neoplasms
  • Carcinoma, Intraductal, Noninfiltrating
  • Continental Population Groups
  • Decision Making
  • Directive Counseling
  • Educational Status
  • Female
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Insurance, Health
  • Male
  • Middle Aged
  • Motivation
  • Neoplasm Staging
  • Prophylactic Mastectomy
  • SEER Program
  • Surveys and Questionnaires

Contralateral prophylactic mastectomy decisions in a population-based sample of patients with early-stage breast cancer

Tools:

Journal Title:

JAMA Surgery

Volume:

Volume 152, Number 3

Publisher:

, Pages 274-282

Type of Work:

Article | Post-print: After Peer Review

Abstract:

IMPORTANCE Contralateral prophylactic mastectomy (CPM) use is increasing among women with unilateral breast cancer, but little is known about treatment decision making or physician interactions in diverse patient populations. OBJECTIVE To evaluate patient motivations, knowledge, and decisions, as well as the impact of surgeon recommendations, in a large, diverse sample of patients who underwent recent treatment for breast cancer. DESIGN, SETTING, AND PARTICIPANTS A surveywas sent to 3631women with newly diagnosed, unilateral stage 0, I, or II breast cancer between July 2013 and September 2014. Women were identified through the population-based Surveillance Epidemiology and End Results registries of Los Angeles County and Georgia. Data on surgical decisions, motivations for those decisions, and knowledge were included in the analysis. Logistic and multinomial logistic regression of the data were conducted to identify factors associated with (1) CPM vs all other treatments combined, (2) CPM vs unilateral mastectomy (UM), and (3) CPM vs breast-conserving surgery (BCS). Associations between CPM receipt and surgeon recommendations were also evaluated. All statistical models and summary estimates were weighted to be representative of the target population. MAIN OUTCOMES AND MEASURES Receipt of CPMwas the primary dependent variable for analysis and was measured by a woman's self-report of her treatment. RESULTS Of the 3631 women selected to receive the survey, 2578 (71.0%) responded and 2402 of these respondents who did not have bilateral disease and for whom surgery type was known constituted the final analytic sample. The mean (SD) age was 61.8 (12) years at the time of the survey. Overall, 1301 (43.9%) patients considered CPM (601 [24.8%] considered it very strongly or strongly); only 395 (38.1%) of them knew that CPM does not improve survival for all women with breast cancer. Ultimately, 1466 women (61.6%) received BCS, 508 (21.2%) underwent UM, and 428 (17.3%) received CPM. On multivariable analysis, factors associated with CPM included younger age (per 5-year increase: Odds ratio [OR] , 0.71; 95%CI, 0.65-0.77), white race (black vs white: OR, 0.50; 95%CI, 0.34-0.74), higher educational level (OR, 1.69; 95%CI, 1.20-2.40), family history (OR, 1.63; 95%CI, 1.22-2.17), and private insurance (Medicaid vs private insurance: OR, 0.47; 95%CI, 0.28-0.79). Among 1569 patients (65.5%) without high genetic risk or an identified mutation, 598 (39.3%) reported a surgeon recommendation against CPM, of whom only 12 (1.9%) underwent CPM, but among the 746 (46.8%) of these women who received no recommendation for or against CPM from a surgeon, 148 (19.0%) underwent CPM. CONCLUSIONS AND RELEVANCE Many patients consider CPM, but knowledge about the procedure is low and discussions with surgeons appear to be incomplete. Contralateral prophylactic mastectomy use is substantial among patients without clinical indications but is low when patients report that their surgeon recommended against it. More effective physician-patient communication about CPM is needed to reduce potential overtreatment.

Copyright information:

© 2017 American Medical Association.

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