Contralateral Prophylactic Mastectomy – An Opportunity for Shared Decision-Making

Most women who have contralateral prophylactic mastectomy (CPM) do not have clear clinical indications for undergoing the procedure, fueling concerns about overuse, as highlighted in the article by Hawley and colleagues.¹ Focusing on improving informed decision-making is one starting point. However, breast cancer surgical decisions are made at an emotional time when fully understanding and weighing the true risks (e.g., surgical complications, self-image, and sexual effects) and benefits (e.g. reduced risk of contralateral cancer) associated with CPM might be difficult for some patients. Anxiety and fear certainly hamper optimal decision-making,^2,3 and greater psychological and emotional support may prove invaluable in this setting. Further complicating informed decision-making is the tendency for people to not believe that risk estimates apply to them personally.⁴

An underlying tension exists between “do no harm,” viewing CPM as medically unnecessary given the lack of demonstrated benefit on recurrence and survival, and respect for patient preferences and autonomy. While CPM might be considered over-treating women without clinical indications, it might still be the right choice for some women for risk reduction, cosmetic and/or emotional reasons. The Institute of Medicine⁵ recently categorized shared decision making in the context of cancer care as “suboptimal”, underscoring a need for better patient-clinician communication. Decision-making surrounding early breast cancer, with respect to CPM in particular, provides an opportunity to encourage a supportive, shared, decision-making approach. Not only should pros and cons of different treatment options be communicated, but there needs to be consideration of the patient's personal circumstances and perceptions, all the while addressing anxiety and concerns about breast cancer recurrence and new primary disease (and the distinction between the two). Finding balance around this issue, like the decision process itself, should be a goal shared by patients and clinicians alike.