Bilateral Mastectomy Without Reconstruction Yields Patient Satisfaction

"Further research including the development of an evidence-based care pathway will be essential to ensure that all [patients] have equitable access to the full range of surgical options for symmetry including contralateral symmetrizing mastectomy [CSM] so they can move forward with their lives in the way that suits them best," according to the study authors.

Patients who underwent a bilateral mastectomy experienced high rates of satisfaction, and complication rates were comparable with those observed to have undergone unilateral mastectomy, according to findings from a systematic review published in Annals of Surgical Oncology.

Of 7 studies that reported on the outcomes of unilateral and bilateral mastectomy, 3 highlighted increased complication rates with bilateral mastectomy, with odds ratios (ORs) ranging from 1.5 (95% CI, 1.0-2.3) to 2.1 (95% CI, 1.3-3.5). Moreover, the 4 remaining studies did not report a significant effect on complication rates with bilateral mastectomy.

There were no significant differences between unilateral and bilateral mastectomy concerning reoperation rates based on findings from 3 studies. One study reported that breast reconstruction was not associated with any complication (OR, 2.6) or major complications (OR, 5.9).

Findings from 1 study indicated that 74.1% of patients were satisfied with their decision to undergo bilateral mastectomy; low satisfaction was typically a byproduct of poor surgeon support surrounding the treatment decision-making process. Providing adequate information on surgical options, care from a specialist breast surgeon, and bilateral mastectomy as the patient’s first selection correlated with high patient satisfaction for this treatment.

Based on multivariate analysis, authors of 1 study highlighted that patients who underwent bilateral mastectomy had significantly less regret compared with those who received unilateral mastectomy (OR, 0.40; P <.001). In another study, patients who underwent bilateral mastectomy plus reconstruction reported higher satisfaction than those who underwent bilateral mastectomy alone, although these outcomes were not significantly different.

“Contralateral mastectomy is a safer alternative to breast reconstruction for [patients] seeking symmetry, and contrary to clinicians’ concerns, decisional regret for bilateral mastectomy is low,” the study authors wrote.

“Education for surgeons is necessary to prevent flat denial and facilitate patient-centered care. Further research including the development of an evidence-based care pathway will be essential to ensure that all [patients] have equitable access to the full range of surgical options for symmetry including contralateral symmetrizing mastectomy [CSM] so they can move forward with their lives in the way that suits them best,” they added.

Investigators of this systematic review evaluated outcomes in at least 1954 patients who received a bilateral mastectomy without reconstruction following unilateral breast cancer across 15 studies. As part of the literature review, investigators searched for primary research studies published on PubMed, MEDLINE, CINAHL, and PsycINFO from January 2020 to August 2022 that assessed clinical or patient-reported outcomes in this patient population.

Abstracts, letters, and conference reports were excluded from the analysis, as were reviews and opinion pieces. Two independent reviewers screened each abstract and determined if prespecified inclusion criteria were fulfilled.

Investigators identified 4 patient cohorts based on the eligible studies: patients with bilateral mastectomy without reconstruction, those with bilateral mastectomy plus reconstruction, those with unilateral mastectomy without reconstruction, and those with unilateral mastectomy plus reconstruction.

Four studies reported conflicting and inconsistent data on the effects of bilateral mastectomy on patient body image. Based on multivariate analysis, bilateral mastectomy with or without reconstruction independently correlated with improvements in “Psychosocial Well-Being” scores. Additionally, multivariate analysis indicated an improvement in sexual well-being scores among patients who underwent immediate reconstruction (P = .0001).

Immediate reconstruction conferred an improvement in “Physical Well-Being” scores based on multivariate analysis (P = .027). In one study, 22% of individuals reported a high level of flat denial, which refers to a stigmatizing attitude towards “going flat” as a valid option from surgical practices. Patients who received treatment from a female surgeon (OR, 0.59) or a breast surgeon specialist (OR, 0.48) had a lower likelihood of experiencing flat denial.

Reference

Griffin C, Fairhurst K, Stables I, Brunsden S, Potter S. Outcomes of women undergoing mastectomy for unilateral breast cancer who elect to undergo contralateral mastectomy for symmetry: a systemic review. Ann Surg Oncol. 2024;31:303-315. doi:10.1245/s10434-023-14294-6