Choosing Bilateral Mastectomy

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Choosing Bilateral Mastectomy

Posted 7/6/2012

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I have written before about the increasing incidence of women choosing bilateral mastectomies when their surgeons don't feel that it is a medically necessary decision. There have been a number of studies recently that demonstrate these growing numbers. Doctors worry about this as, number one, they rarely like unnecessary surgery and try to avoid "removing a healthy organ" and, number two, there is legitimate concern that women don't truly understand the reasons or implications of this choice.

Sometimes, of course, there are sound reasons for bilateral surgery: a woman is BRCA positive or has had more than one breast cancer or has a particularly strong family history or a high level of generalized anxiety or knows herself and knows that she will sleep better at night with both breasts gone. However (and I know this to be true from many conversations), many women believe that they are preserving their future health by removing both breasts.

Here is the catch with that: although cancer, of course, may recur (a local recurrence) in one breast or a different cancer may develop in the other breast, the real health danger is not cancer in the breast but cancer in other parts of our bodies. Cancer in the breast won't kill us. Cancer that has spread to the bones or liver or lungs or brain will eventually do so. It makes zero difference whether or not a breast is still present; the danger is that cells have already spread to other parts of the body. Removing both breasts won't change that; chemotherapy and/or hormonal therapy hopefully will manage that problem. I fully understand that, in the midst of the initial panic around diagnosis, many of us want to do anything we can to stay well. In most cases, removing both breasts won't add anything to that effort.

Here is a new article from The Breast about this, reflecting these realities and the suggestion that this surgical choice is usually made for psychological, not medical, reasons. Here is the abstract and then a link:

Risk, worry and cosmesis in decision-making for contralateral risk-reducing mastectomy: Analysis of 60 consecutive cases in a specialist breast unit

H. Beesley, C. Holcombe, S.L. Brown, P. Salmon

Introduction: Although controversial, use of contralateral risk-reducing mastectomy (CRRM) is increasing. It is not clear whether reduction of objective breast cancer risk or other factors determine decisions for CRRM. We aimed to identify factors that inluence these decisions by scrutinising how decisions were made in one centre.

Methods: We reviewed a consecutive series of 60 patients considered for CRRM in one centre. Data sources, analysed using qualitative methods, were records of routine psychological assessment, surgeon letters, case-notes and interviews with four surgeons.

Results: Perceptions of objective risk did not generally drive patients' requests or surgeons' decisions. Instead, CRRM appeared to be mainly performed for psychological reasons: to reduce patients' cancer worry and to achieve cosmetic benefits.

Conclusion: Routine use of the term 'risk-reducing' surgery masks a clinical decision which usually reflects influences other than risk. As CRRM is often carried out for psychological reasons it follows that evidence about its psychosocial outcomes is needed.