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Original Investigation |

Social and Clinical Determinants of Contralateral Prophylactic Mastectomy

Sarah T. Hawley, PhD, MPH2,1,3; Reshma Jagsi, MD, DPhil2; Monica Morrow, MD4; Nancy K. Janz, PhD3; Ann Hamilton, PhD5; John J. Graff, PhD6; Steven J. Katz, MD, MPH2,3
[+] Author Affiliations
1VA Ann Arbor Healthcare System, Ann Arbor, Michigan
2Medical School, University of Michigan, Ann Arbor
3School of Public Health, University of Michigan, Ann Arbor
4Memorial Sloan Kettering Cancer Center, New York, New York
5University of Southern California, Los Angeles
6Rutgers Cancer Institute of New Jersey, New Brunswick
JAMA Surg. 2014;149(6):582-589. doi:10.1001/jamasurg.2013.5689.
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Importance  The growing rate of contralateral prophylactic mastectomy (CPM) among women diagnosed as having breast cancer has raised concerns about potential for overtreatment. Yet, there are few large survey studies of factors that affect women’s decisions for this surgical treatment option.

Objective  To determine factors associated with the use of CPM in a population-based sample of patients with breast cancer.

Design, Setting, and Participants  A longitudinal survey of 2290 women newly diagnosed as having breast cancer who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries from June 1, 2005, to February 1, 2007, and again 4 years later (June 2009 to February 2010) merged with Surveillance, Epidemiology, and End Results registry data (n = 1536). Multinomial logistic regression was used to evaluate factors associated with type of surgery. Primary independent variables included clinical indications for CPM (genetic mutation and/or strong family history), diagnostic magnetic resonance imaging, and patient extent of worry about recurrence at the time of treatment decision making.

Main Outcomes and Measures  Type of surgery received from patient self-report, categorized as CPM, unilateral mastectomy, or breast conservation surgery.

Results  Of the 1447 women in the analytic sample, 18.9% strongly considered CPM and 7.6% received it. Of those who strongly considered CPM, 32.2% received CPM, while 45.8% received unilateral mastectomy and 22.8% received breast conservation surgery (BCS). The majority of patients (68.9%) who received CPM had no major genetic or familial risk factors for contralateral disease. Multivariate regression showed that receipt of CPM (vs either unilateral mastectomy or breast conservation surgery) was significantly associated with genetic testing (positive or negative) (vs UM, relative risk ratio [RRR]: 10.48; 95% CI, 3.61-3.48 and vs BCS, RRR: 19.10; 95% CI, 5.67-56.41; P < .001), a strong family history of breast or ovarian cancer (vs UM, RRR: 5.19; 95% CI, 2.34-11.56 and vs BCS, RRR: 4.24; 95% CI, 1.80-9.88; P = .001), receipt of magnetic resonance imaging (vs UM RRR: 2.07; 95% CI, 1.21-3.52 and vs BCS, RRR: 2.14; 95% CI, 1.28-3.58; P = .001), higher education (vs UM, RRR: 5.04; 95% CI, 2.37-10.71 and vs BCS, RRR: 4.38; 95% CI, 2.07-9.29; P < .001), and greater worry about recurrence (vs UM, RRR: 2.81; 95% CI, 1.14-6.88 and vs BCS, RRR: 4.24; 95% CI, 1.80-9.98; P = .001).

Conclusions and Relevance  Many women considered CPM and a substantial number received it, although few had a clinically significant risk of contralateral breast cancer. Receipt of magnetic resonance imaging at diagnosis contributed to receipt of CPM. Worry about recurrence appeared to drive decisions for CPM although the procedure has not been shown to reduce recurrence risk. More research is needed about the underlying factors driving the use of CPM.

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Figure 1.
Study Flow Diagram

SEER indicates Surveillance, Epidemiology, and End Results.

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Figure 2.
Predicted Probabilities of Receipt of Treatments by Clinical Indications and Worry About Recurrence

Adjusted for age, race/ethnicity, education, income, stage, and study site.

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