Current Status of Prophylactic Mastectomy
Current Status of Prophylactic Mastectomy
With the advent of methods for determining genetic susceptibility to breast cancer, there is a growing focus on prevention as a primary strategy. In this context, more women will receive information about the role of prophylactic mastectomy as a definitive management strategy. Drs. Ghosh and Hartmann have provided a thorough review of the salient issues in prophylactic mastectomy. Their discussion of the procedure and its history set the stage for further discussion of the relative efficacy of prophylactic mastectomy in reducing the risk of breast cancer in women.Terms at Issue
In the presentation of data demonstrating the efficacy of bilateral and contralateral prophylactic mastectomy, the authors highlight the benefit for a variety of patients. They wisely conclude with the reminder that use of the term "risk-reducing" procedure is preferable to the term "prophylactic," which implies complete protection from breast cancer.
The manner in which surgeons communicate this information is crucial. From 45% to 80% of women at high risk overestimate their chance of developing breast cancer.[1,2] This finding, coupled with the observation that most patients considering this procedure are anxious, reinforces the need to use simple, concrete language. Terms such as "relative risk," "lifetime risk," and "absolute risk reduction" leave many patients bewildered and confused. Communicating information about risk in a variety of ways (both verbally and pictorially) offers women a greater opportunity to understand this information sufficiently to make informed decisions.An Autonomous Decision
Although, as the authors note, most studies report that the majority of women are pleased with their decision to have a prophylactic mastectomy, significant complications can occur. In two reviews of women registered in the Memorial Sloan-Kettering Cancer Center National Prophylactic Mastectomy Registry who had either bilateral or contralateral prophylactic mastectomy,[3-5] several observations emerge. Most women who had the procedure reported being pleased with the outcome. Those who had regrets about the procedure cited the presence of psychological distress coupled with the unavailability of psychoeducation or psychosocial support, both before and after surgery, and dissatisfaction with the cosmetic result.
The authors’ thorough exploration of the surgical and psychosocial sequelae of prophylactic mastectomy reinforces the notion that patients need to be informed and autonomous in their decision to undergo this procedure. Psychological distress prior to the procedure represents a significant cause of difficulty in decision-making and can complicate postsurgical adaptation.
One of the principle causes of regret in our studies at Memorial Sloan-Kettering[4,5] related to the patient’s perception that the decision to have a prophylactic mastectomy was initiated by the physician rather than the patient. Allowing patients to make their own decision by clarifying any misunderstandings they may have increases the probability that they will be satisfied with the outcome. In addition to information provided by the surgeon or a psychiatric consultant, some women find it helpful to talk with others who have undergone the procedure.Psychological Readiness
Although prophylactic mastectomy is risk-reducing surgery, it is also an elective procedure. As surgeons evaluate the appropriateness of prophylactic mastectomy for any patient, they may want to consider the following psychological characteristics that may impair a woman’s ability to make this decision. Both our study and our clinical experience suggest the following indications for further evaluation and referral to psychiatry:
the woman who demonstrates a marked absence of emotional response or who exhibits an overly emotional response to the prospect of having a prophylactic mastectomy, after the surgery, or during reconstruction
the woman who has tremendous difficulty in deciding whether to have a prophylactic mastectomy or who vacillates in her decision-making
the woman who persistently misinterprets or misunderstands information about risk, prognosis, surgical complications, or problems related to reconstruction
the woman who reports having been displeased with previous surgical interventions or has been involved in litigation related to surgery
the woman who describes multiple psychosocial stressors (eg, recent losses, marital dysfunction, or financial/occupational stressors), and
the woman who reports a history of physical or sexual abuse or the presence of a major psychiatric disorder (eg, major depression, bipolar disorder, somatoform disorders, substance abuse, schizophrenia).
In recognition of the impact of these factors, a psychiatric consultation is a recommended step in the decision process at our institution.
Exploration of the following domains represents an adequate assessment of the psychological readiness of patients to undergo a prophylactic mastectomy: Women need to have a working knowledge of their risk of breast cancer, the surgical procedures, and the reconstructive options. An essential aspect includes an evaluation of any psychiatric symptomatology, previous experiences with surgery, and history of abuse that may impair a patient’s ability to make an informed decision. Finally, women and their partners need to consider the effect that the surgery will have on both body image and sexual functioning.Conclusions
The authors remind us that prophylactic mastectomy represents only one of the risk-reducing measures for women at high risk for breast cancer. They stress the importance of proceeding in a stepwise fashion using a multidisciplinary staff, thereby allowing women to process the information they receive and fully explore the impact that this procedure will have on their quality of life.
As the focus of medical intervention continues to shift to include the primary prevention of breast cancer, prophylactic procedures will likely increase. Although a prophylactic mastectomy statistically reduces the chance that a woman will develop breast cancer, the possibility of significant physical and psychological sequelae remain. Careful evaluation, education, and support, both before and after the procedure, may reduce the level of distress and dissatisfaction in these women.
1. Kash KM, Holland JC, Halper MS, et al: Psychological distress and surveillance behaviors of women with a family history of breast cancer. J Natl Cancer Inst 84:24-30, 1992.
2. Valdimarsdottir H, Bovbjerg D, Kash KM, et al: Psychological distress in women with a familial risk of breast cancer. Psychooncology 4:133-141, 1995.
3. Montgomery LL, Tran KN, Heelan MC, et al: Issues of regret in women with contralateral prophylactic mastectomies. Ann Surg Oncol 6:546-552, 1999.
4. Payne DK, Biggs C, Tran KN, et al: Women’s regrets after bilateral prophylactic mastectomy. Ann Surg Oncol 7:150-154, 2000.
5. Borgen PJ, Hill AD, Tran KN, et al: Patient regrets after bilateral prophylactic mastectomy. Ann Surg Oncol 5:603-606, 1998.