Decision For Contralateral Prophylactic Mastectomy Research Articles

Assessment of the effect of the American Society of Breast Surgery guidelines on contralateral prophylactic mastectomy rates for unilateral breast cancer

BackgroundIn July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer. We incorporated these into practice with structured patient counseling and aimed to assess the effect of this initiative on contralateral prophylactic mastectomy rates. MethodsWe evaluated female patients with unilateral breast cancer undergoing mastectomy at our institution from January 2011 to November 2022. Variables associated with contralateral prophylactic mastectomy and trends over time were analyzed using the Wilcoxon rank sum test or χ2 analysis as appropriate. ResultsAmong 3,208 patients, (median age 54 years) 1,366 (43%) had a unilateral mastectomy, and 1,842 (57%) also had a concomitant contralateral prophylactic mastectomy. Across all patients, contralateral prophylactic mastectomy rates significantly decreased post-implementation from 2017 to 2019 (55%) vs 2015 to 2016 (62%) (P = .01) but increased from 2020 to 2022 (61%). Immediate breast reconstruction rate was 70% overall (81% with contralateral prophylactic mastectomy and 56% without contralateral prophylactic mastectomy, P < .001). Younger age, White race, mutation status, and earlier stage were also associated with contralateral prophylactic mastectomy. Genetic testing increased from 27% pre-guideline to 74% 2020 to 2022, as did the proportion of patients with a pathogenic variant (4% pre-guideline vs 11% from 2020–2022, P < .001), of whom 91% had a contralateral prophylactic mastectomy. Among tested patients without a pathogenic variant and patients not tested, contralateral prophylactic mastectomy rates declined from 78% to 67% and 48% to 38% pre -and post-guidelines, respectively, P < .001. ConclusionImplementation of specific patient counseling was effective in decreasing contralateral prophylactic mastectomy rates. While recognizing that patient choice plays a significant role in the decision for contralateral prophylactic mastectomy, further educational efforts are warranted to affect contralateral prophylactic mastectomy rates, particularly in the setting of negative genetic testing.

Contralateral Prophylactic Mastectomy Decision-Making: The Partners' Perspective.

The rate of contralateral prophylactic mastectomy (CPM) continues to rise despite no improvement in survival, an increased risk of surgical complications, and negative effects on quality of life. This study explored the experiences of the partners of women who undergo CPM. This study was part of an investigation into the factors motivating women with early-stage unilateral breast cancer and low genetic risk to opt for contralateral prophylactic mastectomy (CPM). Participating women were asked for permission to invite their partners to take part in interviews. In-depth interviews with partners were conducted using a semi-structured topic guide. A thematic analysis of the data was performed RESULTS: Of 35 partners, all men, 15 agreed to be interviewed. Most perceived their role to be strong and logical. Some hoped their wives would choose a bilateral mastectomy. All felt strongly that the final decision was up to their partners. The partners often framed the decision for CPM as one of life or death. Thus, any aesthetic effects were unimportant by comparison. The male partners had difficulty grasping the physical and emotional changes inherent in mastectomy, which made communicating about sexuality and intimacy very challenging for the couples. In the early recovery period, some noted the stress of managing home life. The experiences of the male partners provide insight into how couples navigate complex treatment decision-making, both together and separately. There may be a benefit to including partners in pre- and post-surgical counseling to mitigate miscommunication regarding the expected oncologic and emotional outcomes related to CPM.

Trends of Contralateral prophylactic mastectomy at the time of ipsilateral breast tumor recurrence

BackgroundContralateral prophylactic mastectomy rates have substantially increased. The study aimed to examine contralateral prophylactic mastectomy (CPM) at the time of ipsilateral breast tumor recurrence (IBTR) and evaluate factors contributing to CPM decision making process. MethodPatients who developed IBTR after BCS from 2011 to 2019 were reviewed. Patient and tumor characteristics, genetic testing and reconstruction details were analyzed. ResultsNinety-six patients had IBTR after BCS and were treated with mastectomy, with 30% electing for a CPM. Patients who underwent CPM were younger, had higher BMI and less comorbidities. A genetic mutation was identified in 19% of patients who underwent testing at the time of IBTR. Tumor characteristics and performing surgeon were not predictors for CPM, however, patients were more likely to undergo CPM if they received reconstruction of the ipsilateral breast with IBTR. ConclusionThis study shows that age, BMI, genetic testing and breast reconstruction are factors contributing to CPM decision at the time of IBTR.

The implementation of a decision aid for women with early-stage breast cancer considering contralateral prophylactic mastectomy: A pilot study

ObjectiveDespite little survival benefit and potential for harm, contralateral prophylactic mastectomy (CPM) rates are increasing amongst early-stage breast cancer patients at low contralateral breast cancer risk. We developed a CPM decision aid (DA) and conducted a pilot implementation. MethodsSurgeons and oncologists recruited eligible patients considering CPM. Consenting patients received the DA, completed a questionnaire and participated in a semi-structured interview. Clinicians were interviewed at study close. ResultsEleven clinicians and 31 patients participated. Three themes emerged: perceived utility and impact of the DA, disagreement regarding timing of delivery and target population, and implementation strategies. Both women and clinicians found the DA valuable, indicating it confirmed rather than changed preferences. Women (all of whom raised CPM themselves), preferred offering the DA early in treatment discussions whilst clinicians favoured targeting women who enquired about CPM. ConclusionA DA about CPM is feasible and acceptable, but questions remain about the role of DAs in these types of decisions where one option has limited medical benefit. Practice implicationsSome women have a high need to make an informed choice about CPM. Tools to support this could include a DA with a clear recommendation against CPM and an explanation why.

Influencers of the Decision to Undergo Contralateral Prophylactic Mastectomy among Women with Unilateral Breast Cancer.

Simple SummaryIn this survey study, we examined survey responses from 397 women with stage 0 to III unilateral breast cancer and found that partners, physicians, and the media were significant relative to the patient’s own influence in their decision to undergo a CPM. The findings of this study may inform policy by highlighting the need for educational aids, programs, or tools that help women with unilateral breast cancer make informed, evidence-based decisions regarding CPM efficacy.(1) Background: The relatively high rate of contralateral prophylactic mastectomy (CPM) among women with early stage unilateral breast cancer (BC) has raised concerns. We sought to assess the influence of partners, physicians, and the media on the decision of women with unilateral BC to undergo CPM and identify clinicopathological variables associated with the decision to undergo CPM. (2) Patients and Methods: Women with stage 0 to III unilateral BC who underwent CPM between January 2010 and December 2017. Patients were surveyed regarding factors influencing their self-determined decision to undergo CPM. Partner, physician, and media influence factors were modeled by logistic regressions with adjustments for a family history of breast cancer and pathological stage. (3) Results: 397 (29.6%) patients completed the survey and were included in the study. Partners, physicians, and the media significantly influenced patients’ decision to undergo CPM. The logistic regression models showed that, compared to self-determination alone, overall influence on the CPM decision was significantly higher for physicians (p = 0.0006) and significantly lower for partners and the media (p < 0.0001 for both). Fifty-nine percent of patients’ decisions were influenced by physicians, 28% were influenced by partners, and only 17% were influenced by the media. The model also showed that patients with a family history of BC had significantly higher odds of being influenced by a partner than did those without a family history of BC (p = 0.015). (4) Conclusions: Compared to self-determination, physicians had a greater influence and partners and the media had a lower influence on the decision of women with unilateral BC to undergo CPM. Strong family history was significantly associated with a patient’s decision to undergo CPM.

Abstract PS9-13: Decision making process and contralateral prophylactic mastectomy

Abstract BACKGROUND The relatively high rate of contralateral prophylactic mastectomy (CPM) among women with early stage unilateral breast cancer has raised concerns particularly with the lack of evidence for a survival benefit related to the CPM and with the low risk of developing contralateral breast cancer among women with early stage breast cancer. Women might be choosing this procedure to ease their fear of recurrence, and by believing that CPM may improve their quality of life; others might be influenced by their partner, physician or media. The purpose of this study was to assess the influence of the partner, physician, or media on the decision making process of women with unilateral breast cancer who decided to undergo CPM. METHODS This is a retrospective study, conducted under MD Anderson Institutional Review Board. Women were identified from an existing cohort of breast cancer patients, age 20-60 years old, who were diagnosed with unilateral breast cancer stage 0 to III, who had no clinical or radiographic evidence of contralateral breast cancer, and who underwent CPM between January of 2010 and December of 2017 at MD Anderson Cancer Center; participants received a link to the quantitative cross-sectional survey using the Red Cap platform, 1341 patients were eligible to participate in the study, of which 397 completed the survey. The survey consisted of 16 questions that were adopted and modified from the Prophylactic Mastectomy Outcomes Study Survey. The survey design provided a numeric description of the factors that are affecting the women decision to undergo CPM; as well as the influence of the partner, physician, or media on the woman’s decision-making process. Exclusion included women who had bilateral breast cancer before undergoing CPM, women who had received any treatment for breast cancer before their initial visit to MD Anderson, women who had bilateral breast cancer before undergoing CPM and patients with incomplete documentation of diagnosis of breast cancer, hormone receptor status or metastatic disease. Incidence of doctor, partner, and media influence were each modeled by logistic regression with adjustment for family history of breast cancer and pathology stage. RESULTS 203/343 (59%) patients reported some doctor influence on the CPM decision. The logistic regression model of the incidence of doctor-influence demonstrated significantly higher overall influence on the CPM decision due to doctors compared to self-determination alone (p=.0006), suggesting that 59% of patients’ decisions were influenced by doctors. 53/189 (28%) patients with partners reported some partner influence on the CPM decision. The logistic regression model of the incidence of partner-influence demonstrated significantly lower overall influence on the CPM decision due to partners compared with self-determination alone (p&amp;lt;.0001,), suggesting that 28% of patients’ decisions were influenced by partners. 36/213 (16%) patients reported some level of media influence on the CPM decision. The logistic regression model of the incidence of media-influence demonstrated significantly lower overall influence on the CPM decision due to media compared with self-determination alone (p&amp;lt;.0001), suggesting that 16% of patients’ decisions were influenced by media. CONCLUSION Partners, physicians, and media all had significant influence (p &amp;lt; 0.05) on the decision-making process of women with unilateral breast cancer to undergo CPM. It is important for women with unilateral breast cancer to fully understand the benefits versus the adverse effect of CPM and make an informed decision regarding the irreversible surgical procedure. The findings of this study may inform policy by highlighting the need for educational aids, programs, or tools that help women with unilateral breast cancer make informed decisions that are evidence-based regarding the efficacy of CPM. Citation Format: Hala Farouk Alameddine, Akshara Singareeka, Clark Andersen, Jesse Selber, Abena Brewster, Carlos H. Barcenas, Abigail Caudle, Baru Arun, Nuhad Ibrahim. Decision making process and contralateral prophylactic mastectomy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-13.

Contralateral prophylactic mastectomy for unilateral breast cancer in women at average risk: Systematic review of patient reported outcomes.

The rate of contralateral prophylactic mastectomy (CPM) in women with early, unilateral cancer is relatively high and is increasing around the world a previous study. Women choose this option for many reasons other than reducing their risk of future cancer, including symmetry, reasons related to breast reconstruction and attempting to manage fear of recurrence. This systematic review evaluated patient-reported quality of life outcomes following CPM. A literature search of MEDLINE, PubMed and PsycINFO was performed to February 2019. Abstracts and full-text articles were assessed for eligibility according to pre-determined criteria. Data were extracted into evidence tables for analysis. A total of 19 articles met eligibility criteria and were included in analysis. These included patient-reported data from 6088 women undergoing CPM. They reported high levels of satisfaction with the decision for surgery, low levels of decisional regret and high satisfaction with cosmesis and reconstruction. Breast-specific and general quality of life was high overall but was even better in women choosing breast reconstruction after surgery. Fear of cancer recurrence was high after CPM. Depression, distress and a negative impact on body image were evident; however, levels were high in both CPM and non-CPM groups. This study provides information that can be used by surgeons and psychologists when counselling women about the potential benefits and harms of CPM. This process must include discussion about the trade-offs such as body image issues and ongoing fear of recurrence in addition to the positive aspect of cancer risk reduction. Women are unlikely to regret their decision for CPM.

Trends in Contralateral Prophylactic Mastectomy

Many breast cancer patients remove their contralateral breast unaffected by cancer, commonly referred to as contralateral prophylactic mastectomy (CPM). CPM has been extensively studied and does not improve survival in patients without deleterious genetic mutation or lobular histology. Despite these limited indications, CPM rates have increased recently. We observed CPM trends in our county safety-net hospital. We performed a retrospective review of women treated for breast cancer who underwent bilateral mastectomy in our institution. We analyzed 100 CPMs: 51% (n = 51) had bilateral breast MRI before CPM, 54% (n = 54) had genetic testing prior to CPM, and 56% (n = 30) had a deleterious genetic result. Another 12% (n = 12) had lobular histology as the primary determinant for CPM. Of patients without genetic mutation or lobular histology, 13% (n = 13) had suspicious MRI findings in the CPM side that drove the decision for CPM. Forty-seven percent (n = 47) had reconstructive surgery documented. Only 42% (n = 42) of patients who underwent CPM had a documented justifiable medical reason. In the future, physician and patient education may decrease unindicated CPM. We also found that 13% of women without a medical indication chose CPM based on suspicious MRI findings, while only 8% of these MRI findings were malignant. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Personalizing Decision-Making for Patients Choosing Contralateral Prophylactic Mastectomy: A Utility Analysis of Genetic Factors and the Relative Risk of Breast Cancer.

There has been an increasing trend of patients with breast cancer electing to undergo contralateral prophylactic mastectomy (CPM), despite the lack of evidence showing long-term survival benefit. We aim to quantify the tiered amount of genetic and surgical complication risk deemed necessary to justify CPM. A review of breast cancer-affiliated genetic mutations and morbidity rates of breast cancer surgery from a single institution was compiled. A survey using a utility analysis was created. Severity of breast cancer genetic risk and morbidity risk warranting CPM was quantified and evaluated. A total of 143 surveys were submitted by women of the general population. Data analysis confirmed previous predictions that at a hypothetical increased risk of contralateral breast cancer (CBC), about twice the proportion of women will elect CPM. With over 10 times the baseline risk and no surgical complications, 98.6% of women chose CPM. There was a decrease in affirmative responses with increasing morbidity. This decrease was least prominent at higher genetic risk, illustrating that when women are at a higher risk of CBC, the surgical morbidity rate has less of an impact on their decision for CPM. At increased risk of CBC, women are likely to elect for CPM. We anticipate that these findings will encourage the growing use of personalized medicine, with the potential to tailor breast cancer treatment plans for each patient's personal genetic profile.

Effect of decision-making resources on satisfaction with decision to undergo contralateral prophylactic mastectomy (CPM)

BackgroundRates of contralateral prophylactic mastectomy (CPM) are increasing, and there are many resources available to help patients with decision-making. We sought to determine how often these were used, and whether their use influenced satisfaction with decision to pursue CPM. MethodsCPM patients at a large academic institution were surveyed regarding factors associated with their CPM decision, and their satisfaction with the same. ResultsOf 58 CPM patients approached to participate, 55 completed the survey with a mean SWD score of 4.85 (range 3.00–5.00). Partner opinion (47.3%), family opinion (45.5%), other cancer patients’ experiences (38.2%), and informational websites (38.2%) were the most frequently cited resources used by CPM patients. On multivariate analysis, controlling for other factors affecting SWD, use of other cancer patients’ experiences predicted above average SWD (p = 0.049). ConclusionThose who use other cancer patients’ experiences to aid in their surgical decision-making enjoy a higher satisfaction with their decision.

Exploring reasons for overuse of contralateral prophylactic mastectomy in Canada.

Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca. This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs. In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%). Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.

Abstract P6-11-01: Field testing of a point-of-care decision support tool for contralateral prophylactic mastectomy

Abstract Background: The majority of women undergoing contralateral prophylactic mastectomy (CPM) overestimate their risk of developing a contralateral breast cancer and incorrectly believe the CPM will substantially improve their overall survival. Using the results of our published micro-simulation decision-analytic model (Davies et al. Breast Cancer Res, 2016), we created and tested a CPM decision support tool to provide patients and breast cancer surgeons with individualized estimates of contralateral breast cancer risk and overall mortality. Methods: The CPM decision support tool had four entry parameters from the micro-simulation model (age, family history of breast cancer, estrogen receptor status, and stage), and a visual depiction of outcomes using icon arrays for chances of developing a contralateral breast cancer and overall mortality with and without CPM. A user-centered design strategy was used with input and iterative refinement from stakeholders, i.e., breast cancer surgeons, patient advocates and breast cancer survivors. The tool was field-tested at MD Anderson Cancer Center with 5 breast cancer surgeons each using the tool with 5 breast cancer patients considering CPM (25 total). Patients completed a knowledge survey immediately before and after viewing the tool and the Decisional Conflict Scale (DCS) after viewing the tool. Surgeons completed the System Usability Scale (SUS) and ratings of the acceptability of the tool. Results: The mean age of patients was 58 years. All patients reported the tool was helpful in making a decision about CPM and would recommend it to others. Knowledge of breast cancer and key CPM facts increased from before to after using the tool (64% vs. 75%, respectively, P&amp;lt;0.05). The mean score on the DCS was 10.5 (standard deviation =14.3) indicating patients were overall sure about the CPM choice. The majority (72%) of patients were unsure of their interest in CPM before viewing the tool. After viewing the tool, 13 (52%) of patients indicated they did not want CPM, 4 (16%) indicated they wanted CPM, and 8 (32%) remained unsure. Surgeons rated the tool as having a positive impact on the decision-making process and SUS scores were highly favorable (mean 93 on 0-100 scale, with 100 indicating highest usability). Conclusion: The CPM decision tool had high overall patient satisfaction and improved knowledge about CPM without affecting decisional conflict. Decision support tools may be used to improve the quality of decision-making about CPM by providing surgeons and their patients with useful individualized information about CPM's impact on relevant clinical outcomes, which may lower the incidence of CPM. Citation Format: Brewster AM, Cantor S, Davies K, Bedrosian I, Parker P, Garrison S, Volk RJ. Field testing of a point-of-care decision support tool for contralateral prophylactic mastectomy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-11-01.

B-Sure: a randomized pilot trial of an interactive web-based decision support aid versus usual care in average-risk breast cancer patients considering contralateral prophylactic mastectomy

The use of contralateral prophylactic mastectomy (CPM) is increasing among breast cancer patients who are at average or "sporadic" risk for contralateral breast cancer. Because CPM provides no survival benefit for these patients, it is not medically recommended for them. Decision support aids may facilitate more informed, higher quality CPM decision. The purpose of this study was to evaluate the feasibility and acceptability of B-Sure, an online decision support aid to facilitate informed decisions regarding CPM, and to compare the impact of B-Sure in increasing CPM knowledge, reducing decisional conflict, and increasing preparedness to make the CPM decision among breast cancer patients at sporadic risk who are considering CPM. Ninety-three patients with unilateral, nonhereditary breast cancer considering CPM completed a baseline survey, were randomized to receive B-Sure or Usual care, and completed a 4-week follow-up survey assessing decisional conflict, preparedness to make the CPM decision, and CPM knowledge as well as self-efficacy, perceived risk, worry, CPM motivations, and the surgical decision. Study participation was high. B-Sure was viewed by almost 80% of the participants and was evaluated positively. At follow-up, patients assigned to B-Sure reported significantly higher clarity regarding the personal values relevant to the CPM decision and higher knowledge about CPM. B-Sure had smaller effects on other aspects of decisional conflict. B-Sure improved CPM knowledge and reduced decisional conflict. Patients considering CPM may benefit from an online decision support aid, but may be sensitive to approaches that they perceive as biased against CPM.

Reframing the conversation about contralateral prophylactic mastectomy: Preparing women for postsurgical realities.

Women with unilateral, early-stage breast cancer and low genetic risk are increasingly opting for contralateral prophylactic mastectomy (CPM), a concerning trend because CPM offers few clinical benefits while increasing risks of surgical complications. Few qualitative studies have analyzed factors motivating this irreversible decision. Using qualitative methods, this study sought to understand women's decision making and the impact of CPM on self-confidence, sense of femininity, sexual intimacy, and peace of mind. Women who had CPM within the last 10years were recruited to participate in the study. We conducted a thematic analysis of the data. Forty-five women were interviewed. When making the decision for CPM, most had incomplete knowledge of potential negative outcomes. However, all believed CPM had more benefits than harms and would confer the most peace of mind and the fewest regrets should cancer return. They knew their contralateral breast cancer risk was low but were not persuaded by statistics. They wanted to do everything possible to reduce their risk of another breast cancer, even by a minimal amount, but most reported paying an unexpectedly high price for this small reduction in risk. Nevertheless, 41 of 45 reported that they would make the same decision again. These findings highlight an opportunity for physicians to reframe the conversation to focus on the patient experience of the tradeoffs of CPM rather than statistical odds of future cancers. Our findings suggest that more data may not dissuade women from CPM but may better prepare them for its outcomes.

Abstract P2-07-09: CPM rate among individuals with breast cancer who underwent multiplex gene testing for hereditary cancer: Single institution experience

Abstract Background: Availability of multiplex gene (MPG) testing for hereditary cancer has led to increase use of panel testing versus single gene testing for hereditary cancer. These panels include high, but also moderate penetrance genes. For some of these genes, associated cancer risk and risk management guidelines do not exist. Furthermore there is a high rate of variant of unknown significant (VUS) findings in non-BRCA genes. Currently, in the absence or minimal available data, health care providers and patients are faced with important risk management decisions, especially regarding preventive surgeries, such as prophylactic mastectomy. Currently, there is no data regarding prophylactic mastectomy rate among patients with breast cancer who underwent (MPG) testing. Therefore, our aim was to evaluate the rate of contralateral prophylactic mastectomy (CPM) in a cohort of individuals who underwent multiplex gene testing. Methods: Eight hundred thirty five patients with breast cancer who underwent MPG testing between the years 2013 and 2016 were identified using Institutional Clinical Cancer Genetics Database. Patients with pathogenic, likely pathogenic variants or who had a VUS were included in the analysis. Results: Of 835 patients with a diagnosis of breast cancer; 105 (13%) had a pathogenic or likely pathogenic mutation: 29 (28%) BRCA1, 26 (25%) BRCA2, 11 (11%) ATM, 2 (2%) BARD1, 3 (3%) BRIP, 9 (9%) CHEK2, 1 (1%) MSH2, 1 (1%) NBN, 5 (5%) PALB2, 4 (4%) PTEN, 1 (1%) RAD51C, 5 (5%) TP53, 4 (4%) CDH1, 2 (2%) MUTYH, 1 (1%) PMS2, 1 (1%) APC (1). A total of 102 (12%) VUS were found. Average age of diagnosis was 44 (Range 21-81). CPM rate was 32% (n=66) for the total cohort. Twenty nine % (n=19) of patients with non-BRCA mutations, 24.2% (n=16) with VUS and 46% (n=31) with BRCA mutations opted for CPM. Conclusion: Overall 32% of breast cancer patients with germline mutations or VUS opt for CPM at our institution. The rate for CPM in non- BRCA mutations carriers is high despite no available data regarding contralateral breast cancer risk and benefit of CPM. This finding should be validated in larger cohorts, including identification of reasons behind decision for CPM in these cohorts. Citation Format: Elsayegh N, Gutierrez Barrera AM, Kuerer HM, Hernandez ND, Litton JK, Arun BK. CPM rate among individuals with breast cancer who underwent multiplex gene testing for hereditary cancer: Single institution experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-07-09.

Abstract P2-12-23: Social networks and the decision to undergo contralateral prophylactic mastectomy

Abstract Background: Multiple studies indicate that the choice of contralateral prophylactic mastectomy (CPM) is increasing, predominantly in women younger than 50. This is despite the lack of demonstrated survival advantage for removing the non-cancerous breast, and contradicts expert medical recommendations, such as those of The National Comprehensive Cancer Network, that discourage CPM unless the patient is at elevated risk for breast cancer (e.g., BRCA1/2 mutation). An underexplored area with regard to selection of CPM is the influence of patients' social and support networks. Breast cancer patients typically involve one or more intimates in their treatment decisions. Further, breast cancer is rarely stigmatized, making it acceptable to disclose the condition, even to non-intimates. Thus, others, in person or using social media, are likely to know when patients are making treatment choices, and may provide information, opinions, or advice that affects these choices. The scope and strength of social network influence on CPM decision-making remains unexplored to date. Methods: Potential participants for this study were identified from Indiana University and Wishard Health Services billing records using the procedure code for bilateral mastectomy during the years 2007-2012. The lists were then curated to identify patients who had undergone CPM. These patients were mailed an introductory letter and study information sheet, after which they were contacted by telephone and the questionnaire administered to those who agreed. Questions focused on the people with whom participants discussed the CPM decision. Results: 117 women of 326 invited agreed to participate. 88% of participants were Caucasian and 11% African-American. The mean age at diagnosis was 50. Most respondents (97%) discussed their surgical options with at least one person other than their surgeons (median = 3, mean = 6.7). The individuals most frequently consulted were spouses/partners, and friends or relatives who had experienced breast cancer. Children, relatives and friends who had not experienced breast cancer, and health care providers or counseling professionals were also engaged in discussion. Most respondents (92%) reported that at least one of the people they talked with (median = 2, mean = 2.6) had some degree of influence on the CPM decision. The average influence of these individuals was 3.2 on a 5-point scale (5 = played a strong role in the decision). Children had the strongest average influence (3.7/5), followed by spouses, and friends or relatives who had experienced breast cancer. Consistent with the sample (all respondents had elected CPM), most people who influenced the respondents were reported to be positive or neutral toward CPM. In the few instances in which the advisor was negative with regard to CPM, respondents reported that this person did not influence their decision. Conclusion: The current study corroborates prior research indicating that breast cancer patients discuss their treatment options with others, and underscores the potential for social and support networks to influence CPM decisions. To reduce the incidence of CPM, it may be necessary for health care professionals to educate and inform large segments of the lay public about the actual benefits and risks of CPM. Citation Format: Baptiste D, Venetis MK, MacGeorge EL, Lagoon J, Mouton A, Pastor R, Friley LB, Clare SE, Bowling MW. Social networks and the decision to undergo contralateral prophylactic mastectomy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-23.

Decision Making and Factors Influencing Long-term Satisfaction With Prophylactic Mastectomy in Women With Breast Cancer

Studies demonstrate an increasing rate of contralateral prophylactic mastectomy (CPM). The purpose of this study is to evaluate decision making and factors influencing women's long-term satisfaction with CPM. Descriptive analysis is used to analyze the results of our designed questionnaire approved by our Institutional Review Board. We searched our institutional cancer registry for patients diagnosed with breast cancer between 2000 and 2010. The studied time frame is of significance as this study is the first to measure response rate in questions examining patient satisfaction for >1 year after undergoing CPM. The questionnaire was mailed to all consented participants to examine factors contributing to the choice of CPM and postoperative satisfaction. Of the 206 women included in the study, 147 were aged up to 50 years. Majority of women who underwent CPM in this cohort was with a bachelor's degree or higher, married or partnered women, and women earning >$60,000/y. Almost all women were "happy with overall surgery" and would recommend CPM to other patients. Psychological factors, such as fear of recurrence, were more commonly associated with the decision for CPM in patients with invasive carcinoma. Opinions of partners, relatives, friends, and physicians further contributed to the decision to undergo surgery. The availability of reconstruction was also an influential factor in the overall decision. The majority of our study participants experienced long-term satisfaction with the surgical procedure of CPM. From our analysis, we can confidently say that fear of cancer recurrence and the opinions of others, among other factors, were influencing contributors toward the decision of undergoing CPM.

Decision Making about Contralateral Prophylactic Mastectomy Among BRCA1/2 Noncarriers with Newly-diagnosed Breast Cancer: Examining Cognitive, Emotional, and Sociodemographic Influences

Abstract Pre-surgical BRCA1/2 genetic testing provides valuable risk information to guide a newly-diagnosed breast cancer patient's decision about whether to have a contralateral prophylactic mastectomy (CPM) to reduce her future risk of cancer in her unaffected breast. Although BRCA1/2 mutation noncarriers face a much lower objective ten-year risk of developing contralateral disease (approximately 3–10%) as compared to the risk of BRCA1/2 mutation carriers (27–37%), some noncarriers still choose to undergo a CPM. The psychosocial factors that motivate this decision are not well understood and warrant investigation. Thus, as part of a prospective study of pre-surgical BRCA1/2 testing, we examined the frequency and psychosocial correlates of the decision to undergo a CPM among newly-diagnosed breast cancer patients who were identified as BRCA1/2 mutation noncarriers. Self-report questionnaire data from 90 BRCA1/2 noncarriers (median age = 43 years, range = 29–59) were analyzed. A sizeable minority of the BRCA1/2 noncarriers (24.4%) chose to undergo a CPM after learning their mutation status (compared to 88% of the 8 BRCA1/2 carriers in the sample). Both bivariate and multivariable analyses indicated that perceiving that one's physician had recommended CPM (OR = 11.17, P = 0.007), perceiving greater risk for contralateral breast cancer (OR = 6.46, P = 0.02), and perceiving greater pros of CPM (OR = 1.37, P = 0.004) were all significantly associated with noncarriers' decision to undergo CPM. However, factors including age, Ashkenazi Jewish ethnicity, breast cancer-related distress, perceived cons of CPM, and decisional conflict regarding CPM were not related to the CPM decision (all ps &amp;gt; 0.05). Results demonstrate that although noncarriers' decision making regarding CPM was unrelated to sociodemographic and emotional factors, their cognitive perceptions of contralateral disease risk, surgical benefits, and physician recommendations were particularly important. Future studies should examine the content of patient-physician communication regarding CPM and hereditary risk in greater detail, and explore how these conversations shape and interact with women's past experiences, emotions, and beliefs to influence their cancer prevention decisions.

Effect of Preoperative MRI on Mastectomy and Contralateral Prophylactic Mastectomy rates at a Community Hospital by a Single Surgeon

Magnetic resonance imaging (MRI) use in the preoperative evaluation of newly diagnosed breast cancer (BC) patients is rising. We evaluated MRI as a function of surgical year with respect to mastectomy and contralateral prophylactic mastectomy (CPM) rates by a single surgeon. From January 2000 to December 2010, 1,279 patients with 1,296 breast cancers were identified. Our breast MRI was installed in April 2006. Mastectomy and CPM rates were evaluated by surgical year and stratified as "pre-MRI" or "MRI" depending on whether surgery occurred before or after April 2006. There was a significant increase in the percentage of patients undergoing MRI in the "pre-MRI" versus "MRI" era (17.2% versus 78.7%, p < 0.001). In contrast, mastectomy rates decreased with 29.9% undergoing mastectomy before 2006 versus 24.5% after 2006 (p = 0.038). Except for 2007, where CPM rates dropped to 7.1%, CPM rates increased from 16.7% in 2000 to 51.9% in 2010 (p = 0.033). The use of MRI, additional MRI findings and additional MRI biopsies were not associated with the decision for CPM. Age <50 was the only factor associated with CPM (RR = 2.12, p = 0.001). In our community hospital, mastectomy rates have decreased despite the increased use of preoperative MRI. MRI alone may not explain the increasing rates of mastectomy reported in other series. CPM rates have dramatically increased over time, seemingly independent of MRI use. Prospective studies are needed to assess the role of surgeon bias, along with other factors, in surgical decision making.

The Contralateral Prophylactic Mastectomy Decision-Making Process

Women facing an early-stage breast cancer diagnosis may elect to have a contralateral prophylactic mastectomy (CPM) to reduce the risk of developing a contralateral breast cancer. In the United States, CPM rates for all surgically treated women with stages I through III unilateral breast cancer increased dramatically from 1998 to 2003. In 1991, the National Institutes of Health Consensus Panel concluded that breast-conserving surgery is an appropriate and preferred treatment for the majority of women with stage I and II breast cancer because it provides survival rates equivalent to those of total mastectomy while preserving the breast. Owing to the near equivalence of the 2 surgical treatment options in terms of survival benefit and recurrence risk, surgical treatment for early-stage breast cancer qualifies as a "preference-sensitive decision" for which no one treatment is best (S. T. ; ). We performed a literature review to identify studies that examined CPM decision making in women facing an early-stage breast cancer diagnosis with the aim of determining the most influential factors affecting her surgical choice. Study outcome measures were largely based on demographic information retrospectively extracted from large databases representing trends rather than revealing influences reflecting preference-sensitive decision making. While we may know demographically, which women choose CPM, we do not know why. To better understand this increasing trend, which greatly impacts patient counseling, prospective research is needed using decision quality methods developed to illuminate factors influencing a woman's decision.