Prophylactic Mastectomies Increasing Despite No Survival Benefit

One of the more concerning trends in breast cancer treatment is the growing use of bilateral mastectomy to treat breast cancer that is present in only one breast. We call this prophylactic contralateral mastectomy – or removal of a normal breast in order to prevent future breast cancer.

A new study of almost half a million women with breast cancer reports that in 2009, 12.7% chose to treat cancer in one breast by removing both breasts, a rate almost triple that in 2002. Unfortunately, the additional surgery added no benefit, as survival rates were no better among women who had bilateral mastectomy compared to those who chose to keep their healthy breast.

The trend towards prophylactic contralateral mastectomy (PCM) is most pronounced among women diagnosed with breast cancer prior to age 55. PCM Rates are highest among women with more advanced disease, the group it is least likely to benefit, but also increasing among those with stage 0 or 1 breast cancer. Other factors associated with use of prophylactic contralateral mastectomy are Caucasian race, higher income and education, larger tumor size, use of breast MRI, family history of breast cancer and increased anxiety and fear of recurrence.

While prophylactic mastectomy does decrease the chance of a new primary breast cancer in the unaffected breast, that risk is less than 1% to start with. The study did not address mastectomy of the affected breast, but in most cases, mastectomy does not improve survival when compared with lumpectomy and radiation therapy.

Why?

Why are so many women opting for bilateral mastectomy, when local treatment with lumpectomy and radiation therapy will in most cases be more than sufficient treatment, and allow for women to keep both their breasts?

Some are crediting Angelina Jolie, who famously underwent bilateral mastectomies for prevention of breast cancer due to a genetic mutation she carries in the BRCA gene.  Yet only about a third of the increase in PCM seen in this study occurred in genetic mutation carriers, so something else is at play here.

I think that something else is the desire for that elusive “peace of mind”, combined with mandatory insurance coverage of reconstructive surgery and the widespread acceptability of breast implants in the general population. Add in a really good nipple tattoo or nipple reconstruction and you’re set to move on from your diagnosis into a breast-cancer free future.

Because nothing says “I’m done” more than a set of new, cancer-free breasts.

Forget that the odds were already well in your favor before the procedure. Or that the procedure does nothing to improve those odds. Or that your peace of mind comes at quite a price – loss of breast sensation, inability to breast feed, and higher cost and complication rates.

I’m not sure what the right answer is to this obvious conundrum.

We’ve done so much to move away from aggressive treatment to allow for improved quality of life and breast preservation compared to the old days, when the Halsted Radical Mastectomy was standard over-aggressive treatment for what in most cases is a localized disease.  Now it seems we are going backwards, but this time at the behest of women themselves.

I suppose that all we can do it take it on a case by case basis, and try to be sure that women are making this important treatment choice with the best data we can give them. In that vein, studies like this provide important information.

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More Reading 

• TBTAM – Angelina, BRCA, Mastectomies, etc
• Growing Use of Contralateral Prophylactic Mastectomy
• Survival Benefit from Prophylactic Mastectomy Small
• Marginal Benefit after Prophylactic Contralateral Mastectomy
• Contralateral Prophylactic Mastectomy Ups Surgical Risks
• Koman.org – Why are rates of bilateral mastectomies rising?
• Angelina Jolie was just the tip of the iceburg
• Time Magazine – The Rate of Double Mastectomies Has Tripled In 10 Years: Study
  
• CNN – The Angeline Jolie Effect