Abstract P2-18-02: Factors associated with contralateral prophylactic mastectomy in young women with breast cancer

Abstract

Background: While younger age at diagnosis has consistently been identified as a predictor of contralateral prophylactic mastectomy (CPM), little is known about how clinical, decisional, and psychosocial factors are related to the decision to undergo CPM in young women with breast cancer. Methods: As part of an ongoing, multi-center cohort study of young women diagnosed with breast cancer at age 40 or younger, we identified 428 women with unilateral Stage I-III disease. Participants were asked to complete surveys by mail that included questions about decision-making and treatments. Tumor characteristics were ascertained via medical record review. Multinomial logistic regression was used to identify predictors of: 1) CPM vs. unilateral mastectomy (UM); 2) CPM vs. breast conserving surgery (BCS). Independent variables with a p-value ≤ 0.15 in bi-variate analyses were included in the final multivariable model. Results: 41% of women had CPM, 29% had UM and 31% had BCS. Median age at diagnosis was 37 (range: 17-40). Most women had stage I or II disease (87%), and estrogen receptor (ER) positive tumors (69%); approximately 14% were carriers of a BRCA 1 or 2 mutation. In the multivariable analysis (Table 1), having a cancer-predisposing mutation, having at least one child, anxiety as measured by the Hospital Anxiety and Depression Scale (HADS), and patient-driven decision making were all associated with a greater likelihood of undergoing CPM, while women who reported their physician made the final decision about surgery were less likely to undergo CPM, compared to both UM and BCS. Additional factors significantly associated with undergoing CPM vs. BCS included nodal involvement, Her2 positivity, and lower BMI. Race/ethnicity, marital status, tumor size, tumor grade, depression (as measured by the HADS), fear of recurrence, and having a first-degree relative with breast or ovarian cancer were not associated with undergoing CPM. Conclusion: Many young women with early stage breast cancer are choosing to undergo CPM. Our findings point to the need for improved communication with patients regarding surgical choices as well as better management of anxiety surrounding diagnosis. Interventions aimed at enhancing risk communication and encouraging shared patient-physician decision-making might be beneficial in this setting. Table 1. Factors associated with: 1) CPM vs. UM; 2) CPM vs. BCS CPM vs. UMCPM vs. BCS OR (95% CI)OR (95% CI)Age at diagnosis0.92 (0.86-1.00)0.97 (0.90-1.04)Mutation positive3.83 (1.60-9.15)14.51 (5.02-41.92)Any nodal involvement0.79 (0.45-1.38)1.93 (1.05-3.55)Her2 positivity0.71 (0.40-1.26)2.24 (1.18-4.25)Having ≥ 1 child2.08 (1.04-4.14)3.25 (1.63-6.48)BMI0.98 (0.92-1.03)0.92 (0.87-0.97)Anxiety1.93 (1.05-3.56)2.31 (1.22-4.35)Decisional involvement (ref = shared) Mainly patient's decision3.47 (1.99-6.06)3.71 (2.09-6.58)Mainly doctor's decision0.14 (0.03-0.63)0.16 (0.03-0.77) Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-02.

Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer

“…Published studies have documented the growth in receipt of CPM in the United States over the last decade, 6,[18][19][20][21] and a few have addressed patient factors driving preferences for more extensive surgery. 2 Other studies have examined surgeon perspectives but they have been limited by small samples, low response rates, or non-US practice settings. 22,23…”

“…1 More patients consider CPM today because of greater awareness of the treatment option and psychological factors that motivate their preferences for the most extensive surgical treatment. 2 Current clinical guidelines suggest that CPM should be discouraged in patients who do not have elevated risk for a second primary breast cancer based on family history and results of genetic testing. 3,4 However, most women who undergo CPM after a diagnosis of breast cancer have an average risk for developing a second breast primary, and rates of contralateral breast cancer have been decreasing steadily owing to the increased use of adjuvant systemic therapy for early-stage disease.…”

Managing psychosocial issues faced by young women with breast cancer at the time of diagnosis and during active treatment

“…Anxiety and depressive symptoms are highest around the time of diagnosis and treatment, and young women experience particularly severe psychological symptoms [7]. For example, women who take on primary decision-making status (as opposed to shared decision-making with their clinician) more often choose to have a contralateral prophylactic mastectomy [8]. They, therefore, stand to benefit from a decision-making approach that ameliorates the emotional burden of breast cancer when deciding among primary surgical options, including reconstruction preferences, and weighing the benefits of adjuvant hormonal therapies against adverse effects.…”