Surgeon Influence on Variation in Receipt of Contralateral Prophylactic Mastectomy for Women With Breast Cancer

Abstract

Importance Rates of contralateral prophylactic mastectomy (CPM) have markedly increased but we know little about the influence of surgeons on variability of the procedure in the community. Objective To quantify the influence of attending surgeon on rates of CPM and clinician attitudes that explained it. Design and Setting Population-based survey study in Georgia and Los Angeles County. Participants We identified 7810 women with stages 0-II breast cancer treated in 2013–15 through the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery, (70% response rate, n=5080). Surveys were also sent to 488 attending surgeons identified by the patients, of whom 377 responded (77% response rate). Main Outcomes and Measures We conducted multilevel analyses to examine the impact of surgeon influence on variations in patient receipt of CPM using information from patient and surgeon surveys merged to SEER data. Results The patient mean age was 62; 30% had an increased risk of 2nd primary cancer, and 16% received CPM. Half of surgeons (52%) practiced for >20 years and 30% treated >50 new breast cancer patients annually. Attending surgeon explained a large amount (20%) of the variation in CPM controlling for patient factors. The odds of a patient receiving CPM increased almost 3-fold (OR 2.8, 95% CI 2.1,3.4) if she saw a surgeon with a practice approach one standard deviation above a surgeon with the average CPM rate (independent of age, diagnosis date, BRCA status and risk of 2nd primary). One quarter (25%) of the surgeon influence was explained by attending attitudes about initial recommendations for surgery and responses to patient requests for CPM. The estimated rate of CPM was 34% for surgeons who least favored initial breast conservation and were least reluctant to perform CPM vs 4% for surgeons who most favored initial breast conservation and were most reluctant to perform CPM. Conclusion and Relevance Attending surgeons exert strong influence on the likelihood receipt of CPM after diagnosis of breast cancer. Variations in surgeon attitudes about recommendation for surgery and response to patients request for CPM explain a substantial amount of this influence.

Differences in physician opinions about controversial issues surrounding contralateral prophylactic mastectomy (CPM): A survey of physicians from accredited breast centers in the United States

“…Many of our findings are consistent with other studies that have examined surgeon opinion on indications for CPM, however, a notable finding from our study was the difference in CPM recommendations among the physician subspecialties. Plastic surgeons were significantly more likely to recommend CPM than other physician specialties for nearly every clinical scenario.…”

Are breast conservation treatment rates optimized for Asian women with symptomatic malignancies?

“…In the current study, 59% of women who underwent NAC had sufficient downstaging for successful BCT, a proportion closer to the rate reported by van Mackelenbergh et al Katz et al demonstrated that surgeon attitude was associated with a substantial difference in the type of surgical treatment received . An estimated contralateral prophylactic mastectomy rate of 34% occurred for surgeons who least favoured initial BCT, compared with a contralateral prophylactic mastectomy rate of 4% for surgeons who most favoured BCT . This difference is consistent with the difference of more than 40% in BCT rates between the current study cohort and another Asian group undergoing NAC, demonstrating that a significant variation in BCT rates exists within study populations of similar ethnic composition and tumour sizes in Asia.…”

“…Not only is this lower than the generally expected BCT rate after downstaging suggested by Masood, it is also significantly lower than 63–68% BCT rates reported in a large multicentre study . In the current study, 59% of women who underwent NAC had sufficient downstaging for successful BCT, a proportion closer to the rate reported by van Mackelenbergh et al Katz et al demonstrated that surgeon attitude was associated with a substantial difference in the type of surgical treatment received . An estimated contralateral prophylactic mastectomy rate of 34% occurred for surgeons who least favoured initial BCT, compared with a contralateral prophylactic mastectomy rate of 4% for surgeons who most favoured BCT .…”

Assessing the additional surgical risk of contralateral prophylactic mastectomy and immediate breast implant reconstruction

“…It has been suggested that decision making for CPM is highly influenced by surgeons, given their significant role in patient education [40,75,86]. The National Comprehensive Cancer Network Practice Guidelines stresses the importance of physicians creating a "shared decision-making environment" with their patients [87].…”