SAN FRANCISCO – Fear and a desire for control over breast cancer may drive women to choose mastectomy over less aggressive management, a qualitative study of 30 patients has shown.
She interviewed 15 women who were candidates for breast-conserving surgery but chose unilateral mastectomy and 15 average-risk women who were candidates for surgery in one breast but also chose prophylactic contralateral mastectomy.
Fear led patients to overestimate their risk of local recurrence and contralateral cancer and to misunderstand their odds of dying of breast cancer. The fear combined with wanting to eliminate and control the risk of cancer resulted in the patient choosing mastectomy or bilateral mastectomy, factors that probably are contributing to increasing rates of mastectomy for early-stage breast cancer, Dr. Andrea M. Covelli reported in a poster at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
When deciding on treatment, the women sought out multiple sources of information but gave greatest weight to the experiences of people they’d known with breast cancer and information from breast cancer survivors. It was the patients, not clinicians, who raised the topic of contralateral prophylactic mastectomy, which some patients chose in an attempt to eliminate any risk of contralateral breast cancer.
"More surgery is seen as more control," reported Dr. Covelli of the University of Toronto. A better understanding of patients’ decision process may help physicians be better able to discuss issues important to their patients in making treatment decisions.
Dr. Covelli conducted semistructured one-on-one interviews with patients with early-stage breast cancer chosen from five hospitals in the greater Toronto area to represent a variety of ages and ethnicities. Twelve were treated at academic cancer centers, 6 were treated at academic noncancer centers, and 12 were treated at community medical centers.
She identified several themes in the results. The diagnosis brought shock and fear. Patients discussed both breast-conserving surgery and unilateral mastectomy during their surgical consultation, during which the physician discouraged contralateral prophylactic mastectomy. Patients relied on multiple sources of information in their decision making, but the greatest impact came from the experiences of others with breast cancer, she reported.
Women who chose unilateral mastectomy did so most often out of fear of recurrence and the misguided notion that it would give them a survival advantage. Occasionally, they chose unilateral mastectomy to avoid radiation therapy.
Women who also chose contralateral prophylactic mastectomy initiated discussions about it, which their surgeons then discouraged. These patients chose it anyway because they overestimated the risk of contralateral cancer and mistakenly believed it would improve their chance of survival. Occasionally they added contralateral prophylactic mastectomy for body symmetry.
In essence, patients chose these more aggressive surgeries because they were actively trying to control their cancer outcomes and ensure that they "never have to go through this again," Dr. Covelli said.
The study cohort had a mean age of 55 years, with ages ranging from 36 to 84 years.
Dr. Covelli has received funding from Roche Canada and the Canadian Breast Cancer Foundation Physician Fellowship Award.
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