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Anxiety Stimulates Double Mastectomies

Posted 1/12/2014

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  This is an ongoing topic, but it is so important, and, since women are being diagnosed and needing to make surgical decisions and perhaps just starting to read and think about this, it is well worth bringing it up again. As you likely know, there has been a growing incidence of women, who don't medically need them, opting for bilateral mastectomies. Note that we are not thinking here about women who have tested positive for the BRCA1 or BRCA2 gene or women who have bilateral breast cancer or women who have been told by their surgeon, for whatever unique and personal reason, that this would be the safer choice. For the overwhelming majority of us, there is not a medical reason to remove a healthy breast. Doing so does not increase our chances of survival, actually has no impact at all on the diagnosed breast cancer in the contralateral breast.

  So why are women choosing to have this additional surgery? They may have been convinced by someone or something that symmetry would be easier to achieve with bilateral mastectomies and reconstruction. One woman last week (and this was a new twist for me) told me that her PT had suggested she have two, rather than the planned single, mastectomy as she "found that women were more satisfied". (whatever that means) Most often, however, and study after study confirms this, women opt for bilateral mastectomies mostly out of fear. In spite of what their doctors tell them (that a wide excision/lumpectomy is just as effective for them or that they do need a mastectomy, but only need one), too many women think they are protecting their futures with this additional surgery.

  This has become a big enough problem that surgeons are talking about ways to better share the facts and information with their patients, trying to help them clearly understand the realities. It goes without saying (except I guess it does not because here I am saying it) that I will always support a woman's right to choose whatever makes sense for her and helps her sleep at night. But I surely wish that everyone really understood the facts when making these huge decisions that can't be changed. If someone finds that she remains highly anxious about her remaining breast, she can always return to the surgeon and talk about another mastectomy. But, once it is off, it is gone.

  This is an excellent article from JNCI about this important issue:

 Anxiety Fuels Growing Trends in Double Mastectomy
By Charlie Schmidt

Researchers have documented a growing trend in breast cancer treatment in recent years: Women diagnosed with cancer in one breast are increasingly having both breasts removed, even without genetic risks that warrant the procedure, which is called contralateral prophylactic mastectomy (CPM). These women face very low risks for contralateral breast cancer, and the original tumor is much more likely to recur in the bones or elsewhere in the body. So why these women choose CPM, along with the potential for surgical complications, has been a source of speculation.

A study in the September Annals of Internal Medicine reveals that many newly diagnosed women overestimate their risk of contralateral breast cancer and choose CPM out of a desire to extend life, despite paradoxically being aware that the procedure doesn’t increase survival.

“They understand objectively that CPM doesn’t extend life,” said lead author Shoshana Rosenberg, ScD, MPH, an epidemiologist at the Dana–Farber Cancer Center in Boston. “Yet on an emotional level they don’t think that conclusion applies to them.”

The paper raises some challenging issues. Nancy Davidson, MD, oncologist and professor at the University of Pittsburgh School of Medicine, said the findings show how clinicians sometimes fail to adequately counsel women during their decision-making process.

“If we did a better job describing the risks and benefits of CPM, then fewer women would be inclined to have it,” she said.

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