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Understanding Risk and Surgical Decisions

Posted 9/20/2013

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  This is another in my continuing series about surgical decisions. Although I will always support a woman's decisions for herself, I often feel that women do not fully understand the realities of cancer risk and the consequences of surgery. Surgeons, in general, resist removing healthy organs and usually push back, at least a bit, if a woman wants her other (non-cancer) breast removed. They may also push back a bit if a woman chooses mastectomy with lumpectomy/wide excision would be an equally sound medical decision.

  The situation is entirely different for women who carry one of the BRCA gene mutations. For them, the recommendation is often to have bilateral mastectomies. For the rest of us, that is rarely the surgeon's suggestion although increasing numbers of women make that choice. I met this week with two women who are leaning in that direction. One is a large breasted woman in her 60s who needs a mastectomy because of multi-focal disease (meaning that there is cancer is several areas in her breast); her primary motivation is not wanting to be so lopsided. I suggested that she talk with her surgeon about a possible breast reduction on the other side, and that gave her another option to consider. (and question: why in the world hadn't the doctor mentioned this possibility?) The second woman is in her early 40s, has DCIS in one breast, and is in an understandable panic about her life. She clearly needs more information about DCIS and about the risk of developing cancer in the contralateral breast

  This is a brief article from The New England Journal's Physician First Watch that gives a nice summary of the issues.

.Women Who Elect Contralateral Prophylactic Mastectomy May Overestimate Risk

 By Kelly Young

Many young women with unilateral breast cancer who choose to undergo prophylactic bilateral mastectomy
overestimate their risk for cancer in the other breast, according to an Annals of Internal Medicine study.
Roughly 125 women aged 40 years and younger who had contralateral prophylactic mastectomy after a diagnosis of unilateral breast cancer completed surveys 2 years postsurgery.
Most women (94%) said that improving their survival odds was an important factor in their decision, but only 18% thought that women who undergo contralateral prophylactic mastectomy live longer than those who don't.
Women who did not carry BRCA mutations estimated that 10% of women would develop contralateral breast cancer without prophylactic mastectomy within 5 years. The actual risk is 2%–4%. Mutation carriers had a more accurate risk perception.
Only 51% said their physicians provided reasons not to undergo surgery.
Editorialists write: "The apparent discordance between patient perceptions and realistic expectations provides a teachable opportunity for physicians treating newly diagnosed patients with breast cancer." They recommend that physicians communicate the actual risk, potential mastectomy complications, the odds of distant metastases, and mastectomy alternatives.



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