Choosing a Mastectomy
Making surgical decisions is always difficult. Sometimes, there is a clear medical recommendation of either a lumpectomy/wide excision or a mastectomy. If a breast has been previously radiated or if the surgeon cannot achieve clean margins or if the size and/or location of the tumor make a smaller surgery impossible, a surgeon will suggest the need for a mastectomy. Sometimes, however, in the absence of a clear medical recommendation, a woman will still opt for this larger surgery.
Over the years, when I have talked with women in the throes of this process, I have recognized the strong influence of both the medical situation and the personal one. A woman's experiences, relationships, history, and feelings impact her decision, too. A recent articel in the Journal of the National Cancer Institute" explores some of the reasons for this choice. Here is a quote and then a link to the full article:
The JNCI study may be the first to evaluate the role of the patient's family and friends in the choice of surgery. When someone else was present for the discussion about treatment, women more often received mastectomy. Less acculturated Latinas placed the most importance on others' opinions, and a substantial proportion of women took their spouse's opinion into account when making the decision. Women who said that their spouse was very important in decision making were less likely to receive an initial mastectomy than women who indicated that their spouse was not or marginally important in their decision making. "This highlights the important role that others may play in shaping treatmentdiscussions and, ultimately, decisions," said Dr. Hawley.
Beliefs, Perceptions, and Evidence
At face value, said Dr. Katz, "a patient's preference for mastectomy might seem irrational, but there are a number of issues involved. We know that patients' concerns about cancer recurrence can greatly influence their surgical treatment decisions and drive preferences for mastectomy. Policymakers and some physicians might underestimate such powerful cognitive and emotional factors that favor the more aggressive treatment."
"A high quality decision can be defined as one that is fully informed, and consistent with the decision maker's underlying values," Dr. Hawley explained. This suggests that the process of decision making might be more important than the actual decision made, said Dr. Katz.
Researchers who study outcomes have found that patients can be more influenced in their treatment decision by how they understand, interpret, and value the factors they are facing than by the data that clinicians often use to buttress their recommendations. Such knowledge about patient preferences and their decision-making process is the foundation for improved risk communication and counseling.