When the doctor recommends against the surgery a breast cancer patient wants

More women with breast cancer are electing to have both breasts removed, even when cancer affects only one breast. The procedure, called contralateral prophylactic mastectomy (CPM), is a more complex surgery that has not been shown to improve survival.

A new study from the University of Michigan Comprehensive Cancer Center examines the complex interaction between patients' desires for the most extensive treatment and surgeons' responsibility to minimize harm.

The population-based survey, published in JAMA Surgery, found that few patients sought a second opinion or went to a different hospital when their surgeon recommended against CPM. Further, patients were overwhelmingly satisfied with their treatment, even when their surgeon dismissed CPM with little discussion.

"We hypothesized that patients whose first surgeons recommended against CPM might report less satisfaction, and might be more likely to seek second opinions and pursue surgery by a second surgeon," says the study's lead author Steven J. Katz, M.D., M.P.H., professor of medicine and of health management and policy at the University of Michigan. "But in this study, an initial recommendation against CPM had little impact on overall satisfaction with treatment or on decisions to pursue or act on a second opinion."

The study is the first to explore what transpires after a newly diagnosed unilateral breast cancer patient first meets with a surgeon to discuss her options. The survey asked 1,140 patients who considered CPM about the extent to which CPM was discussed during their first consult and recorded patient satisfaction with their surgery decisions, whether or not they received a second surgical opinion and whether a second surgeon operated.

Key findings

In this large, diverse sample of women newly diagnosed with unilateral breast cancer, about half considered CPM. A quarter of those patients reported that their surgeon recommended against CPM; another 30 percent reported no substantial discussion about CPM.

In general, dissatisfaction with the surgical decision was uncommon - just 7.6 percent of respondents. Dissatisfaction was very low - only 4 percent—among patients whose surgeons discussed CPM but did not recommend against it. While still relatively low, the level of dissatisfaction was significantly higher, 15 percent, in instances when the surgeon recommended against CPM with no substantive discussion of the option.

A second opinion was sought by one in five respondents, and one in 10 patients went on to have surgery performed by a second surgeon. Women whose first surgeon recommended against CPM were not more likely to seek a second opinion or to receive surgery by a second surgeon.

This is the latest in a series of studies by the Michigan Medicine-based Cancer Surveillance and Outcomes Research Team, examining both breast cancer patient and provider perspectives on treatment decision-making in general and issues of potential overtreatment in particular. It is the first to capture information about the newly diagnosed patient's first surgical consult.

"The increased attention to and preference for CPM among patients for whom it is not a clinical imperative is a relatively recent phenomenon," says Katz. "It's one of many considerations on the minds of patients we know are understandably anxious and who may feel they need to make treatment decisions quickly after diagnosis."

Katz notes that doctors are looking for guidance on how to address patients' concerns and respect their wishes without exposing them to more extensive treatment than medically called for or losing them to another surgeon.

"About 95 percent of breast cancer patients are treated by the first surgeon they see," says Katz. "It's so important in those initial consultations that the patient and the surgeon feel free to discuss all of the options and work together to determine the best path forward."

While more research is needed to develop and test tools to help facilitate these crucial conversations, in the meantime Katz believes this research should provide some reassurance to surgeons. "It demonstrates that recommending against CPM won't necessarily result in patients second-guessing the treatment choices they make in partnership with their primary surgeon," he says, "or looking elsewhere for advice or care."