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.
With the advent of methodsfor determining geneticsusceptibility to breast cancer, there is a growing focus on prevention as aprimary strategy. In this context, more women will receive information about therole of prophylactic mastectomy as a definitive management strategy. Drs. Ghoshand Hartmann have provided a thorough review of the salient issues inprophylactic mastectomy. Their discussion of the procedure and its history setthe stage for further discussion of the relative efficacy of prophylacticmastectomy in reducing the risk of breast cancer in women.
Terms at Issue
In the presentation of data demonstrating the efficacy ofbilateral and contralateral prophylactic mastectomy, the authors highlight thebenefit for a variety of patients. They wisely conclude with the reminder thatuse 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 iscrucial. From 45% to 80% of women at high risk overestimate their chance ofdeveloping breast cancer.[1,2] This finding, coupled with the observation thatmost patients considering this procedure are anxious, reinforces the need to usesimple, concrete language. Terms such as "relative risk,""lifetime risk," and "absolute risk reduction" leave manypatients bewildered and confused. Communicating information about risk in avariety of ways (both verbally and pictorially) offers women a greateropportunity to understand this information sufficiently to make informeddecisions.
An Autonomous Decision
Although, as the authors note, most studies report that themajority of women are pleased with their decision to have a prophylacticmastectomy, significant complications can occur. In two reviews of womenregistered in the Memorial Sloan-Kettering Cancer Center National ProphylacticMastectomy Registry who had either bilateral or contralateral prophylacticmastectomy,[3-5] several observations emerge. Most women who had the procedurereported being pleased with the outcome. Those who had regrets about theprocedure cited the presence of psychological distress coupled with theunavailability of psychoeducation or psychosocial support, both before and aftersurgery, and dissatisfaction with the cosmetic result.
The authors’ thorough exploration of the surgical andpsychosocial sequelae of prophylactic mastectomy reinforces the notion thatpatients need to be informed and autonomous in their decision to undergo thisprocedure. Psychological distress prior to the procedure represents asignificant cause of difficulty in decision-making and can complicatepostsurgical adaptation.
One of the principle causes of regret in our studies atMemorial Sloan-Kettering[4,5] related to the patient’s perception that thedecision to have a prophylactic mastectomy was initiated by the physician ratherthan the patient. Allowing patients to make their own decision by clarifying anymisunderstandings they may have increases the probability that they will besatisfied with the outcome. In addition to information provided by the surgeonor a psychiatric consultant, some women find it helpful to talk with others whohave undergone the procedure.
Although prophylactic mastectomy is risk-reducing surgery, itis also an elective procedure. As surgeons evaluate the appropriateness ofprophylactic mastectomy for any patient, they may want to consider the followingpsychological characteristics that may impair a woman’s ability to make thisdecision. Both our study and our clinical experience suggest the followingindications for further evaluation and referral to psychiatry:
the woman who demonstrates a marked absence of emotionalresponse or who exhibits an overly emotional response to the prospect of havinga prophylactic mastectomy, after the surgery, or during reconstruction
the woman who has tremendous difficulty in decidingwhether to have a prophylactic mastectomy or who vacillates in herdecision-making
the woman who persistently misinterprets ormisunderstands information about risk, prognosis, surgical complications, orproblems related to reconstruction
the woman who reports having been displeased withprevious surgical interventions or has been involved in litigation related tosurgery
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 sexualabuse 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 psychiatricconsultation is a recommended step in the decision process at our institution.
Exploration of the following domains represents an adequateassessment of the psychological readiness of patients to undergo a prophylacticmastectomy: Women need to have a working knowledge of their risk of breastcancer, the surgical procedures, and the reconstructive options. An essentialaspect includes an evaluation of any psychiatric symptomatology, previousexperiences with surgery, and history of abuse that may impair a patient’sability to make an informed decision. Finally, women and their partners need toconsider the effect that the surgery will have on both body image and sexualfunctioning.
The authors remind us that prophylactic mastectomy representsonly 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 amultidisciplinary staff, thereby allowing women to process the information theyreceive and fully explore the impact that this procedure will have on theirquality of life.
As the focus of medical intervention continues to shift toinclude the primary prevention of breast cancer, prophylactic procedures willlikely increase. Although a prophylactic mastectomy statistically reduces thechance that a woman will develop breast cancer, the possibility of significantphysical and psychological sequelae remain. Careful evaluation, education, andsupport, both before and after the procedure, may reduce the level of distressand dissatisfaction in these women.
1. Kash KM, Holland JC, Halper MS, et al: Psychologicaldistress and surveillance behaviors of women with a family history of breastcancer. 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 regretin women with contralateral prophylactic mastectomies. Ann Surg Oncol 6:546-552,1999.
4. Payne DK, Biggs C, Tran KN, et al: Women’s regrets afterbilateral prophylactic mastectomy. Ann Surg Oncol 7:150-154,2000.
5. Borgen PJ, Hill AD, Tran KN, et al: Patient regrets after bilateralprophylacticmastectomy. Ann Surg Oncol 5:603-606,1998.