Elsevier

The Breast

Volume 28, August 2016, Pages 107-120
The Breast

Review
Contralateral prophylactic mastectomy (CPM): A systematic review of patient reported factors and psychological predictors influencing choice and satisfaction

https://doi.org/10.1016/j.breast.2016.04.005Get rights and content

Highlights

  • 17 studies exploring patient reported factors influencing CPM were identified.

  • Studies were primarily cross-sectional and retrospective.

  • No study included a theoretical framework to guide research.

  • Main reasons for CPM were fear of breast cancer and desire for symmetry.

Abstract

Objective

Conduct a systematic review of quantitative and qualitative studies exploring patient reported factors and psychological variables influencing the decision to have contralateral prophylactic mastectomy (CPM), and satisfaction with CPM, in women with early stage breast cancer.

Methods

Studies were identified via databases: Medline, CINAHL, Embase and PsycINFO. Data were extracted by one author and crosschecked by two additional authors for accuracy. The quality of included articles was assessed using standardised criteria by three authors.

Results

Of the 1346 unique citations identified, 17 were studies that met the inclusion criteria. Studies included were primarily cross-sectional and retrospective. No study utilised a theoretical framework to guide research and few studies considered psychological predictors of CPM. Fear of breast cancer was the most commonly cited reason for CPM, followed by cosmetic reasons such as desire for symmetry. Overall, women appeared satisfied with CPM, however, adverse/diminished body image, poor cosmetic result, complications, diminished sense of sexuality, emotional issues and perceived lack of education regarding alternative surveillance/CPM efficacy were cited as reasons for dissatisfaction.

Conclusion

Current literature has begun to identify patient-reported reasons for CPM; however, the relative importance of different factors and how these factors relate to the process underlying the decision to have CPM are unknown. Of women who considered CPM, limited information is available regarding differences between those who proceed with or ultimately decline CPM.

Introduction

Breast cancer (BC) is the most common cancer in women worldwide, with nearly 1.7 million new cases diagnosed in 2012 [1]. This represents about 12% of all new cancer cases and 25% of all cancers in women [1].

Women with a history of BC are at increased risk of developing future BC including contralateral breast cancer (CBC). Risk of CBC depends on a range of genetic factors, family history, and possibly characteristics of the primary cancer (lobular histology, multicentricity). In a summary of recent studies, Portschy and Tuttle [2] reported an annual CBC risk of 0.4% among BRCA1/2-negative women with estrogen receptor (ER) positive BC taking hormone therapy, and 0.5% among those with ER negative BC, although a lower annual rate of 0.19% has been reported for Australian low-risk women [3]. Risk of metastases has been estimated to be 26 times greater than CBC, although metastatic risk for any given woman is highly variable, depending on the stage and phenotype of her breast cancer [4]. Five year survival rates after CBC are equivalent to that after primary breast cancer (88–98% depending on tumour size).

Treatments commonly offered at the time of first breast cancer diagnosis to reduce risk of metastases (endocrine therapy and chemotherapy) also reduce risk of CBC. The most effective option for reducing risk of CBC, however, is contralateral prophylactic mastectomy (CPM), the surgical removal of the unaffected breast. CPM reduces risk of CBC by 90–95% [5], [6]. Nonetheless, due to the low base-rate of CBC, the risk-reduction offered from CPM is relatively low in women without BRCA1/2 mutations or a strong family history. Furthermore, CPM does not reduce risk of metastases [7], [8].

CPM can also incur significant costs and harms. Complications occur in 15–20% of bilateral mastectomies with reconstruction, and in half these cases, complications occur in the contralateral breast [9]. Complications may significantly delay adjuvant therapy thus potentially increasing risk of metastatic disease [9]. Other negative CPM outcomes include perceived poor cosmetic results, negative impacts on sexuality, femininity and body image, and depression [10], [11], [12]. Thus the Society of Surgical Oncology (USA) recommends CPM only for women with clinical indications for high risk of future BC [13].

For women where CPM is not clinically indicated, the decision to have CPM is considered a preference-sensitive decision [14] and women are required to weigh up the potential harms and benefits of the procedure. Despite the relatively small benefits of CPM for women at low-risk of CBC, rates of CPM have been dramatically increasing [15]. Results from a recent study in the USA indicated that 2% of BC patients elected CPM in 1998 compared to over 12% in 2011, with a greater increase (30%) observed in women under 40 years [16].

As a result of increasing rates of CPM, in addition to the patient-preference nature of the decision, researchers have identified a need to isolate factors influencing the decision to have CPM, especially for women where there are limited or no clinical indications for the procedure. Women with a high risk of developing breast cancer (who have not been diagnosed with cancer), may consider bilateral prophylactic bilateral mastectomy (BPM). Although this might be considered to be a similar decision to CPM, as both procedures aim to reduce risk and are based on patient preferences, women considering BPM have not had cancer nor surgery to remove one breast, therefore there are likely differences in predictors and preferences.

A recent systematic review of CPM decision-making, which included articles published before 2011, concluded that studies of factors influencing the decision to have CPM were primarily of retrospective data from large databases, and thus represented CPM population trends rather than identifying factors influencing decision-making at the individual level [17]. Subsequent research began to ask women about factors influencing their decision regarding CPM. Whilst recommendations for decisional support in this area have been made [18], limited evidence is available regarding patient reported factors influencing this decision. The aim of this systematic review is to identify patient-reported and/or psychological factors influencing the decision to have CPM and/or satisfaction with CPM in the current literature, to guide future interventions aimed at supporting women in making an informed decision about CPM.

Section snippets

Search strategy

A systematic search of relevant databases including MEDLINE, PsycINFO, CINAHL and Embase was conducted. An eligibility checklist was developed (Table 1) to assess articles for inclusion. The list of search terms is presented in Table 2 in the appendix.

Information extraction and quality assessment

Decisions regarding selection were made by one author (BA) and verified by two co-authors (PB and JJ). A data extraction table was used to summarise variables such as type of participants, study design, methods, measures and themes/outcomes. The

Results

The search strategy yielded 1346 unique citations and based on their title and/or abstract 181 full-texts were selected for review (Fig. 1). Of these, 17 articles met the inclusion criteria. Examination of selected studies revealed three key areas used to guide organisation of review findings, including: (i) patient reported factors influencing the decision to have CPM (Table 4) (ii) psychological factors predicting the decision to have CPM (Table 5) and (iii) patient reported factors

Discussion

Studies reviewed explored patient reported and psychological factors influencing the decision to have, or satisfaction with, CPM, primarily in women who had previously made the decision to have CPM years prior. We focused on women with low-risk of CBC for whom there were no clinical indications for CPM, in order to understand potential reasons for the increasing rate of CPM over recent years.

The included studies were primarily descriptive and included cross-sectional and retrospective designs.

Conflict of interest statement

None declared.

Acknowledgements

This project is funded by the Australian and New Zealand Breast Cancer Trials Group (ANZBCTG). KAP is an Australian National Breast Cancer Foundation Fellow. PB is an NHMRC Senior Principle Research Fellow.

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