Exploring Reasons for Overuse of Contralateral Prophylactic Mastectomy in Canada

Abstract

Background Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca.Methods This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs.Results In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%).Conclusions Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.

Bilateral Mastectomy in Women With Unilateral Breast Cancer

“…Women may experience a heightened psychological reaction, fearing an event that is theoretical, of low likelihood, and occurring well into the future. Squires et al reported that anxiety from fear had influenced women with breast cancer to preferring contralateral mastectomy. Graves et al associated breast cancer–specific distress with contralateral prophylactic mastectomy.…”

“…In Canada, clinicians seem to not raise the issue of contralateral prophylactic mastectomy unless the patient brings it up or is considering unilateral mastectomy . Canadian physicians have reported that, if a woman had expressed a desire for contralateral prophylactic mastectomy, it was difficult to change her mind.…”

“…Canadian physicians have reported that, if a woman had expressed a desire for contralateral prophylactic mastectomy, it was difficult to change her mind. Furthermore, 42% of physicians were not aware of guidelines regarding contralateral prophylactic mastectomy . Presumably, they were unaware of position statements from societies discouraging the procedure in average-risk women with unilateral breast cancer .…”

“…Presumably, they were unaware of position statements from societies discouraging the procedure in average-risk women with unilateral breast cancer . Medical and radiation oncologists are less likely to support contralateral mastectomy than are surgeons . Kantor et al found that only 33% of medical oncologists and 28% of radiation oncologists supported contralateral mastectomy insurance coverage in women of average risk, compared with 55% of surgical oncologists and 76% of plastic surgeons.…”

Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States

“…20 As contemporary reconstructive practices provide more realistic breast reconstructions, the desire for more symmetrical, esthetic breasts play a key role in the decision-making process. 45 This is subsequently acknowledged by CPM consensus statements; however, greater emphasis must be placed on the multi-specialty approach to this decision and the utilization of psychological input to mitigate the anxiety concerns. 16,26,46 Patients should have pre-operative counseling which addresses the irreversible nature and potential cosmetic and emotional consequences of CPM as patients have been documented…”