Women with unilateral breast cancer have a high risk of developing cancer in the unaffected breast. These patients have many treatment options; however, the rate of contralateral prophylactic mastectomy (removal of the unaffected breast) have been steadily rising. A study conducted by Tuttle and colleagues in the Journal of Clinical Oncology found that the rate of contralateral prophylactic mastectomy doubled from 1998 to 2003. This increasing trend continued to the end of the study period, without any plateau. The authors also noted that patients appeared to be increasingly choosing either minimal surgical procedures or a bilateral mastectomy, instead of a unilateral mastectomy.
The study didn't address the reasons why increasing numbers of women are choosing this treatment, but Marisa Weiss, MD, founder and president of http://www.breastcancer.org, explains that the reasons are complex and highly individual. "Both medical circumstances and emotional issues may be making it a more common option," she says.
Women opting for contralateral prophylactic mastectomy may have more extensive disease, vascular and lymphatic invasion, or more than one cancer in the breast, Weiss explains. "There is more public awareness of the genetics of breast cancer, and a lot of young women are getting genetic counseling. The whole process may reveal a strong family or genetic history, and patients are given real information that they should be concerned about."
Weiss also points out that breast cancer has become very visible over the past 30 years, and while women have become more aware of the disease, they are also increasingly worried. "When women are diagnosed with breast cancer, many want to do everything possible to prevent it from happening a second time."
Tuttle and colleagues also found that the rate of contralateral prophylactic mastectomy increased from 1.8% of all surgeries in 1998 to 4.5% in 2003. In addition, the percentage of contralateral prophylactic mastectomy accounted for 11% of all mastectomies in 2003, up from 4.2% in 1998. The patients most likely to choose contralateral prophylactic mastectomy in this study were non-Hispanic
whites, women with lobular breast cancers, and those with a previous cancer diagnosis. A younger age was also associated with a significantly higher rate of contralateral prophylactic mastectomy. Among those with surgically treated breast cancer, 6.7% of women ages 18 to 39 underwent contralateral prophylactic mastectomy, as opposed to 1.3% of women ages 70 to 79. "Many of these young women are physically active, they see themselves as healthy and living a healthful lifestyle and are shocked by a breast cancer diagnosis," says Weiss.
However, Tuttle and colleagues point out that contralateral prophylactic mastectomy is "aggressive and irreversible; it is also not necessary for preventing contralateral breast cancer in most patients." The majority of participants in their study had three surgical options: breast conserving surgery, unilateral mastectomy, or bilateral mastectomy. Among 152,755 patients with breast cancer, 59,460 underwent unilateral mastectomy while 4,969 opted for contralateral prophylactic mastectomy, even though a single mastectomy was also an appropriate option.
Survival Benefit and Satisfaction. Tuttle and colleagues acknowledge that other studies have shown that contralateral prophylactic mastectomy can decrease the risk of contralateral breast cancer, but a clear survival benefit has not been determined.
"But there doesn't necessarily need to be a straightforward survival advantage for this to be a viable option for breast cancer patients," says Marybeth Singer, MS, APRN, BC, AOCN, ACHPN, an NP from the Gillette Center for Breast Oncology in Boston. "We need to look at the quality of survival. For many women, the rigors of undergoing routine follow-up and waiting for that 'all clear sign' are extremely stressful."
This was the case for Helen, a 59-year-old NP who works in a large New York City hospital and had a bilateral mastectomy. Helen says, "I couldn't take the stress of frequent follow-ups, mammograms, and worrying about more surgery. It's the best decision I ever made. I was back to work in three weeks."
Singer points out that cancer treatment is highly individualized. "Even if the approach [to treatment] is not one that you as a nurse would make for yourself," she says, You need to support the patient and help her get the facts straight.
"Nurses are often the first-line people that patients see, so our role is extremely important. But nurses need to be aware of the literature and work with patients to manage their anxiety, lower their risk, and improve lifestyle factors."
The majority of women who undergo contralateral prophylactic mastectomy tend to be satisfied with that decision. Geiger and colleagues, as published in the Journal of Clinical Oncology in March 2006, surveyed 519 women who underwent contralateral prophylactic mastectomy and found that 86.5% were satisfied with their decision. More than three-quarters reported a high level of contentment regarding quality of life, and psychosocial outcomes were generally similar to those in breast cancer survivors who had not undergone the procedure.
"Being satisfied doesn't mean that everything is perfect," says Geiger. "But most women really believe it was a good decision for them."
However, Geiger also points out that their data showed that women who chose contralateral prophylactic mastectomy were not at a particularly higher risk for recurrence. "Their risk was not greater as compared with women who didn't have it done," she says. "They may have just had more anxiety about breast cancer."
Women have also reported a better cosmetic outcome when a bilateral mastectomy is performed.
They are likely to have better symmetry; breast reconstruction may be more difficult when performed on only one side. "In focus groups, women have reported that it [reconstruction] was one of the reasons [for prophylactic contralateral mastectomy], although not the predominant reason," says Geiger. "Clearly, many factors go into making this decision."
Decision Making Process. Tuttle and colleagues reported on a review of the National Prophylactic Mastectomy Registry that found the most common reason patients selected prophylactic contralateral mastectomy was physician advice. However, a 2005 survey by Nekhlyudov and colleagues in the Journal of the National Cancer Institute Monographs showed that 45% of respondents (N = 431) made the decision to have contralateral prophylactic mastectomy on their own. Another 37% reported that they considered the opinion of their physician, while only 3% reported that the physician "primarily made the decision."
Geiger suspects that the rates of contralateral mastectomy may continue to rise, especially if magnetic resonance imaging (MRI) of the breast increases in popularity. "An MRI scan is more sensitive than a mammogram and more likely to pick up small irregularities in the unaffected breast. The American Cancer Society is looking at expanding its guidelines for breast MRI, and if that comes to pass, we are likely to see this trend continue."
Roxanne Nelson, BSN, RN