By Monica J. Smith

Las Vegas—The rapid growth of prophylactic mastectomy has been quite a puzzler in an era that favors increasingly minimal operations. Recent research suggests a surgeon’s practice environment may contribute strongly to a patient’s surgical decisions.

Andrea Covelli, MD, a general surgery resident at the University of Toronto, Ontario, Canada, designed a qualitative study to evaluate the influence of surgeons on the growing mastectomy rate, and to ascertain differences between surgeons in Canada and the United States. She presented her findings at the 2014 annual meeting of the American Society of Breast Surgeons.

Dr. Covelli identified 45 surgeons—23 from Ontario and 22 from the United States—to participate in the study, which consisted of telephone interviews ranging from 29 to 93 minutes. The participants averaged 15 years in practice, represented both academic and nonacademic institutions, and included both fellowship- and non–fellowship-trained breast surgeons.

After a line-by-line comparative analysis of the interviews, Dr. Covelli was able to identify repeating ideas, overall concepts and themes exploring how various factors might contribute to overall mastectomy rates.

Surgeons from both countries described an increasing rate of mastectomies over the past 10 years, Dr. Covelli said. “More notably, they shared that patients frequently came in requesting a contralateral prophylactic mastectomy, and they’ve experienced an increase in patients undergoing both unilateral and contralateral prophylactic mastectomy as treatment for early-stage breast cancer in average-risk, nongenetic-carrier patients.”

Recommendations and Consultation

Dr. Covelli identified similarities and differences in how the surgeons handle consultation and recommendations. Both groups of surgeons inform patients that breast-conserving therapy (BCT) with radiation is equivalent to unilateral mastectomy for early-stage, average-risk patients. Canadian surgeons frequently recommend BCT, citing Canadian surgical guidelines as a basis for that recommendation. In contrast, U.S. surgeons usually do not offer a recommendation.

“Some U.S. surgeons would do so if directly asked by the patients, whereas others would leave it entirely up to the patient’s choice,” Dr. Covelli said. “This may in part be reflective of legislative requirements; some states have alternative therapy laws, which mandate the discussion of all surgical treatment options.”

She also found that Ontario surgeons strongly advise against the use of contralateral prophylactic mastectomy (CPM) and advocate for treating only the diseased breast. Although U.S. surgeons neither endorse nor encourage CPM, they frequently leave the decision up to the patient.

The two groups of surgeons also differ in their discussions regarding reconstruction, with Canadian surgeons broaching the topic only if patients are considering a unilateral mastectomy. “In the U.S., the discussion around reconstruction was introduced to every patient, very early in their initial consultation,” Dr. Covelli said.

Again, this is in part reflective of legislative mandates, but it is also reflective of access, she said, noting that although reconstruction in Canada is mainly limited to patients at academic or high-volume centers, the U.S.-based surgeons all had good access to immediate reconstruction.

In both countries, patients who choose unilateral mastectomy are sent for consultation with a reconstructive surgeon. “Many of the surgeons at high-volume centers in both Canada and the United States shared that not infrequently patients would return requesting bilateral surgery with reconstruction as they had been informed they would achieve better symmetry and balance,” Dr. Covelli said.

The Role of Magnetic Resonance Imaging

Use of magnetic resonance imaging (MRI) is thought to influence a preference for mastectomy due its high rate of false positives, which may provoke patient fears and sway them toward the more extensive procedure. Dr. Covelli found that the Canada-based surgeons were always the physician who ordered the preoperative MRI, which allowed them to selectively use the MRI if so indicated, and to counsel patients on the benefits and limitations of MRI.

“In contrast, the U.S. surgeons showed that MRI was often completed before they saw the patient, frequently at a side imaging facility,” she said. “This limited the surgeons’ ability to be selective about the use of MRI, and to counsel patients about the high rate of false positives, and the sensitivity that may lead to additional workups.”

The Surgeon, the Environment

In summary, Dr. Covelli found that surgeons from both countries tended to be of one mind: Describe BCT and unilateral mastectomy as equivalent options, but do not endorse the use of CPM.

“It was always the patients who initiated the request for bilateral mastectomy or unilateral and CPM,” Dr. Covelli said.

The differences lay in the practice milieu, which had the ability to shape the surgical consultation and influence patients’ decisions.

“In conclusion, I didn’t find any role of the surgeon encouraging the choice for more extensive surgery, but the practice environment factors, MRI, reconstruction legislation and guidelines, are in fact inadvertently influencing the increasing mastectomy rates,” Dr. Covelli said.

Victor Zannis, MD, FACS, medical director of the Comprehensive Breast Center of Arizona, Phoenix, believes Dr. Covelli’s research accurately describes the factors affecting women’s surgical decisions.

“We are seeing a significant number of women choosing mastectomy or adding contralateral mastectomy in situations where these procedures do not improve survival,” Dr. Zannis said. “As a surgeon who counsels women in this arena daily, I believe the surgeon has a lot of influence on the decision making.”

It is imperative, he said, that surgeons make it clear to their patients that more conservative surgery with equal survival is advantageous for its potential to obviate the downsides associated with more extensive procedures: postoperative pain, complications, the need for reconstruction and cost.

“We should let the patient know it’s OK to save their breasts in cases of equal survival, essentially giving them permission to not do radical surgery for their cancer,” he said.