Preventive Mastectomy May Not Benefit, but Decision Tool Can Help

Laurie Kirstein, MD, FACS

Laurie Kirstein, MD, FACS

Contralateral prophylactic mastectomies (CPM) have been a growing trend among women at average risk of breast cancer with a diagnosis of cancer in one breast, but the procedure is not medically recommended for this population.

“For patients who are at an average risk of breast cancer—meaning they don’t have the BRCA mutation or a strong family history of breast cancer—the risk of getting a second breast cancer over the course of their lifetime is incredibly low,” said Laurie Kirstein, MD, FACS, a surgical oncologist at Rutgers Cancer Institute of New Jersey.

“Removing tissue that is not predisposed to getting breast cancer doesn’t change that risk, prevent recurrence, or allow patients to avoid chemotherapy. It’s the tumor itself that decides all of these things.”

Kirstein attributed the increase in bilateral preventive mastectomies in part to popularized cases in the media, but said that many women are not properly educated about the procedure and its benefit in relation to their risks.

In order to help women contemplating CPM, Kirstein and Sharon Manne, PhD, associate director for Cancer Prevention, Control, and Population Science at the Rutgers Cancer Institute, are developing an educational online tool to aid in patients’ decision-making processes.

The National Cancer Institute recently awarded the investigators a 2-year $404,089 grant for their research.

Using a series of interactive models, the site will provide information about recurrence cancer versus a new primary cancer, the purpose of prophylactic mastectomies, and the effects after CPM.

The tool will also cover family history of breast cancer and populations appropriate for CPM to reduce their risk.

“There is a clinical need for greater patient education with regard to making this complex decision,” Manne said in a statement. “Decision support aids that address the risks and benefits of the procedure can be helpful in promoting a well-informed choice.”

During the first year of the project process, which runs through July 2017, Kirstein and Manne are creating the modules and content. They are currently interviewing patients who have gone through the decision-making process to identify pivotal influences in their ultimate choice.

At the end of 2015, the site will be rolled out to a few patients to ensure that the results accurately reflect the accounts of the previous interviewees.

In the second year, the decision tool will be administered to 80 women who are currently contemplating CPM.

“The decision aid is meant to educate women so that they can come up with the decision that’s right for themselves,” Kirstein said. “And a lot of times we find that when women are adequately educated about the lack of medical reason to do it and the outcomes they’ll feel afterward, a lot of them choose not to do it.”

Mastectomies result in loss of sensation and, in many cases, loss of the nipple. Advances in reconstructive surgery have made women feel more confident about CPM, Kirstein noted, but even good reconstruction can still lead to body image issues and may not restore sensation.

An increase in celebrities choosing CPM has also made the procedure seem more socially acceptable. However, some women—such as Angelina Jolie—are appropriate candidates for CPM because they carry the BRCA mutation and are predisposed to getting another breast cancer.

“For this population, it is truly a risk-reducing procedure,” Kirstein said. “But when you’re not at high risk of breast cancer, taking off the other breast doesn’t prevent it. It’s just a big surgery.”