More women diagnosed with early stage breast cancer are choosing to have their unaffected, healthy breast removed as a preventative measure—but the proportion varies considerably by state, according to a study published Wednesday in JAMA Surgery.
According to the New York Times, there is no evidence that removing a healthy breast in women with breast cancer extends lives. Further, both the American Board of Internal Medicine and the American Society of Breast Surgeons advise against the procedure unless a woman has a high risk of forming a new cancer.
Researchers who conducted the study noted that, over the last decade, there has been an increase in contralateral prophylactic mastectomies (CPM)—having both breasts removed—among women who are diagnosed with invasive cancer in only one breast, "despite the lack of evidence for survival benefit." The researchers wrote that it was unclear whether the trend varied by state or whether it was "correlated with changes in proportions of reconstructive surgery."
As such, the researchers set out "to determine state variation in the temporal trend and in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery." They reviewed data on 1.2 million women ages 20 and older from 45 states and Washington, D.C., who had been diagnosed with early stage invasive breast cancer in one breast between Jan. 1, 2004, and the end of 2012.
Overall, the researchers found that 58.4 percent of the women included in the study had surgery to remove cancer in their affected breast but did not have surgery on their healthy breast. An additional 32.9 percent of women had a single mastectomy on their affected breast, and 8.7 percent had CPMs. Among women who had surgery, the percentage who had CPMs increased from 4.5 percent of patients in 2004 to 13 percent in 2012, the researchers found. Younger women were more likely than older women to have CPMs, according to the study. The proportion of women who had CPMs increased from:
- 10 percent in 2004 to 33 percent in 2012 among women ages 20 to 33; and
- 4 percent in 2004 to more than 10 percent in 2012 among women ages 45 and older.
The researchers wrote that an increase in CPM rates was "evident in all states," but found that "the magnitude of the increase varied substantially across states." For instance, the researchers found that the share of women ages 20 to 44 who had CPMs increased from 14.9 percent to 24.8 percent in New Jersey. In comparison, that rate increased from 9.8 percent to 32.2 percent in Virginia. According to the study, more than 42 percent of women in five states—Colorado, Iowa, Missouri, Nebraska, and South Dakota—who were younger than 45 and were diagnosed with early breast cancer opted to have CPMs.
The researchers also found that the share of women aged 20 to 44 who were diagnosed with early-stage breast cancer, had CPM, and had reconstructive surgery increased from 2004 to 2012. However, the researchers wrote that the increase did not correlate with the share of women who had CPM.
Ahmedin Jemal, the study's senior author and vice president of surveillance and health services research at the American Cancer Society, said the increase in CPM rates might stem from "differences in culture" and "provider recommendations." He added that research suggests women are less likely to have CPM when they are informed and when the decision to have the procedure is driven by a physician.
Jemal also pointed to the "Angelina Jolie effect" as a possible explanation. Jolie, an actress, had both breasts removed when she learned she had a genetic mutation that increases the risk of breast cancer. However, Jemal said there is no evidence to support CPM in an average-risk woman.
E. Shelley Hwang, chief of breast surgery at Duke Cancer Institute who was not involved in the study, said the findings "underscore[e] the fact that women are making this decision" to have CPM "out of anxiety rather than medical necessity." She said the findings suggest there "are important regional differences in how communication occurs between patient and surgeons," adding, "it is clearly not plausible that there are biologically based regional differences."
Lisa Newman, director of the Henry Ford Health System's breast oncology program, in a commentary accompanying the study, wrote that surgeons have "an ethical and moral imperative" to ensure patients have accurate information, as well as that the treatments patients receive "prioritize optimal oncologic outcomes." She added that while doctors should "avoid being paternalistic," they should also make sure patients do not make treatment decisions impulsively (Doheny, HealthDay/U.S. News & World Report, 3/29; Nash et al., JAMA Surgery, 3/29; Rabin, New York Times, 3/29).
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