A breast cancer patient’s decision to undergo contralateral prophylactic mastectomy is heavily influenced by the surgeon’s attitude toward the procedure, even if that is at odds with the prevailing consensus or guidelines, according to a new report published online September 13 in JAMA Surgery.
In a study of more than 3000 patients with stage 0 to II breast cancer, Steven J. Katz, MD, MPH, and colleagues found that the odds of a patient receiving contralateral prophylactic mastectomy (CPM) increased nearly threefold if she saw a surgeon whose propensity to perform it placed them one standard deviation above average (ie, in the 84th percentile rather than the 50th percentile) for propensity to perform CPM.
In general, clinician attitudes toward CPM in curable cases have undergone a “sea change” in recent years, in favor of more conservative approaches, Dr Katz, from the Department of Internal Medicine in the University of Michigan School of Medicine, Ann Arbor, and colleagues write. “Yet, rates of CPM have increased over the past decade, largely owing to greater patient awareness and interest in the procedure.”
That fact, plus the findings of this study, point to a need for better communication between surgeon and patient, and clearer guidelines about CPM, the authors say.
Study Details and a Hypothetical Patient
To gauge attitudes toward CPM, the researchers recruited participants from the iCanCare study, which examined attitudes toward breast cancer tests and treatments among patients with early-stage disease and clinicians in Georgia and Los Angeles County. The patients ranged in age from 20 to 79 years and were contacted approximately 2 months after surgery between July 2013 and August 2015.
As part of this study, patients were asked to identify their attending surgeon, who was then also invited to participate. Survey responses were not shared between patients and physicians, and all respondents were anonymous.
To gauge each surgeon’s attitude toward CPM and breast conservation therapy (BCT), the authors presented them with the hypothetical case of a 55-year-old woman with a normal screening mammogram and no family history of breast cancer. “In this case, bilateral screening ultrasonography showed a 1.2-cm solid mass, and a core biopsy demonstrated infiltrating ductal carcinoma,” they explain. Estrogen receptor and progesterone receptor expression were 95% and 90%, respectively, and human epidermal growth factor 2 was negative.
The authors measured the surgeons’ views using 2 scales. The first was designed to measure the clinicians’ feelings about initial BCT, with a higher score indicating they favored that approach. The second scale assessed reluctance to perform CPM even if requested by the patient, with a higher score indicating greater reluctance.
Effect of Surgeon Attitudes on Findings
A total of 3353 women with stage 0 to II breast cancer and 349 surgeons participated in the study. Patients had a mean age of 61.9 years (standard deviation, 11). Of those patients, 604 (18%) had ductal carcinoma in situ, 1868 (56%) had stage I breast cancer, and 881 (26%) had stage II cancer. Fifty-eight patients (2%) had a BRCA mutation, and 952 (28%) were considered to be at high risk for a second primary tumor.
As for treatment, 2156 patients (64%) underwent BCT, 663 (20%) had unilateral mastectomy, and 534 (16%) had CPM.
Of surgeons who favored BCT, 96% indicated that they would “probably or definitely not recommend” CPM to the hypothetical patient, and 76% said they would recommend against it. Among surgeons who said they would perform CPM if the patient requested it, the most common reasons were to provide peace of mind, avoid patient conflict, and improve cosmetic outcomes.
Dr Katz and colleagues performed a multilevel logistic regression analysis to estimate the effect of surgeon attitudes on the likelihood of CPM. They controlled for variables related to patients (age, BRCA mutation status, and risk for a second primary cancer) and surgeons (sex, years in practice, and annual volume of newly diagnosed breast cancer cases treated). Geographic location also was figured into the calculation.
Overall, patient factors explained about 15% of variability in the likelihood of CPM, but surgeon factors accounted for 20%, the authors report.
“The odds of a patient receiving CPM would increase 2.8-fold (95% [confidence interval], 2.1-3.4) if she were to see a surgeon with a practice approach 1 [standard deviation] above a surgeon with the mean CPM rate (independent of age, date of diagnosis, BRCA status, and risk of recurrence),” they write.
“The estimated rate of CPM was 34% for surgeons who least favored initial breast conservation and were least reluctant to perform CPM vs 4% for surgeons who most favored initial breast conservation and were most reluctant to perform CPM.”
Of the influence attributable to surgeons, 25% could be accounted for by a combination of their own attitudes toward initial recommendations for surgery and responses to patient requests for CPM.
Study limitations include the “inevitable decay in the sample given the requirement for completed surveys from both the surgeon and the patient,” and including only residents of two large regions of the country.
“Facts, Not Fear”
The findings suggest that “variability in communication and the lack of tools and resources to guide the surgical discussion have created disparate patient experiences,” Julie A. Margenthaler, MD, and Amy E. Cyr, MD, from Washington University School of Medicine, St. Louis, Missouri, write in an invited commentary.
“Patients who are provided education tools regarding the decision between BCT and mastectomy are more likely to opt for BCT.” The goal, they add, should be “to standardize the methods and information patients receive to ensure that their decisions are based on facts, not fear.”
Surgeons should address this “growing clinical conundrum,” the study authors conclude. Specifically, they suggest developing ways to dispel patients’ misconceptions about the benefits of more extensive surgery and concerns regarding the management plan.
The study authors and editorialists have disclosed no relevant financial relationships.
JAMA Surg. Published online September 13, 2017. Article full text, Commentary extract
For more news, join us on Facebook and Twitter
Tidak ada komentar:
Posting Komentar