By Dr. Victoria Haney and Dr. Christy Teal
As of 2020, breast cancer has become the most common cancer in the world (study). Overall survival has significantly increased in the past 20 years due to improvements in chemotherapy, endocrine therapy, genetic testing, and imaging studies used for screening (ACS statistics). Still, 1 in 8 women will be diagnosed with breast cancer during their lifetime. As women surgeons, the likelihood that our friends, family members, patients, or even ourselves will be affected by breast cancer is almost guaranteed.
For most women, breast cancer is diagnosed in its early stages due to widespread screening initiatives for annual mammograms (ASBS screenings). Many patients with invasive cancers undergo breast-conserving therapy, or lumpectomy, along with adjuvant radiation. This treatment is well-established to have similar survival outcomes when compared to mastectomy (study). During treatment, patients will often ask the question, “What if it happens again on the other side?” As surgeons, it is our role to educate women that the chances of this happening are very low, with more recent studies citing a less than 2% risk of cancer on the contralateral side (study). Yet despite this information, more and more women (study) are opting to prophylactically remove their unaffected breast at the same time as their initial surgery.
There has been a steady rise in contralateral prophylactic mastectomies (CPM) in recent years (study). CPM is a procedure where the healthy breast is removed to almost completely negate the risk of developing future cancer on that side. The primary reason for this trend is the fear of developing future cancer on the unaffected side. Some studies report that this is due to an overestimation of risk by patients. Other studies attribute it to the increased utilization of MRI for dense breast tissue. Although CPM is not itself without risk, most patients who have undergone the procedure reported that they would do it again, even after experiencing complications. Long term, the majority of patients are satisfied with their decision to undergo CPM (study).
The topic of CPM is a controversial one in the world of breast surgery. Some surgeons are opposed to the idea and discourage their patients from undergoing CPM, due to no increased survival benefit. While it is true that there is no survival benefit to undergoing CPM when compared to recommended annual screenings, there is something to be said about how we are defining survival. Yes, more women are living full, healthy lives past their breast cancer diagnosis. But anyone who has been through the process will tell you, most come out with scars, both figuratively and literally. One patient we recently saw in clinic comes to mind; a young career woman in her early 40s without family history or genetic abnormalities, presented with a contralateral breast cancer. She had to undergo chemo the first time she was diagnosed in her 30s and was distraught when she found out that she would likely require another round. She expressed to us that she wished she had undergone bilateral mastectomies when she was initially diagnosed. For many women, the thought of undergoing repeat surgery, chemotherapy, or endocrine therapy is enough to consider CPM. Additionally, there may be daily insidious thoughts about if the cancer will come back or not. For some women, choosing to undergo CPM gives them back their peace.
As surgeons, it is our responsibility to provide our patients with the risks and benefits of their treatment plan. In a world where medicine is becoming more personalized and where more women are surviving breast cancer, it’s time to start treating each patient individually. This may mean that CPM is the best treatment for some patients, while for others it’s continued surveillance. Every woman has different values and goals for herself, and as surgeons, it is our job to provide patients with all of the information, so that they can make an informed decision. Ultimately, it is time that we listen.
To learn more about this topic and to read personal stories from patients and physicians alike, check out the book, No Longer Radical, authored by Dr. Rachel Brem and Dr. Christy Teal.
- Wilkinson, L., & Gathani, T. (2022). Understanding breast cancer as a global health concern. The British Journal of Radiology, 95(1130), 20211033.
- Fisher, B., Anderson, S., Bryant, J., Margolese, R. G., Deutsch, M., Fisher, E. R., … & Wolmark, N. (2002). Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New England Journal of Medicine, 347(16), 1233-1241.
- Sparano, J. A., Gray, R. J., Makower, D. F., Pritchard, K. I., Albain, K. S., Hayes, D. F., … & Sledge Jr, G. W. (2018). Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. New England Journal of Medicine, 379(2), 111-121.
- Burke, E. E., Portschy, P. R., & Tuttle, T. M. (2014). Contralateral prophylactic mastectomy: are we overtreating patients?. Expert review of anticancer therapy, 14(5), 491-494.
- Wong, S. M., Freedman, R. A., Sagara, Y., Aydogan, F., Barry, W. T., & Golshan, M. (2017). Growing use of contralateral prophylactic mastectomy despite no improvement in long-term survival for invasive breast cancer. Annals of surgery, 265(3), 581-589.
- Abbott, A., Rueth, N., Pappas-Varco, S., Kuntz, K., Kerr, E., & Tuttle, T. (2011). Perceptions of contralateral breast cancer: an overestimation of risk. Annals of surgical oncology, 18, 3129-3136.
- Hawley, S. T., Jagsi, R., Morrow, M., Janz, N. K., Hamilton, A., Graff, J. J., & Katz, S. J. (2014). Social and clinical determinants of contralateral prophylactic mastectomy. JAMA surgery, 149(6), 582-589.
- Anderson, C., Islam, J. Y., Elizabeth Hodgson, M., Sabatino, S. A., Rodriguez, J. L., Lee, C. N., … & Nichols, H. B. (2017). Long-term satisfaction and body image after contralateral prophylactic mastectomy. Annals of surgical oncology, 24, 1499-1506.
Victoria Haney, MD is a general surgery resident at The George Washington University Hospital in Washington, DC. She is currently in her dedicated research year with the Department of Breast Surgery at the GW Medical Faculty Associates. She is originally from Roswell, NM, and completed medical school at The Pennsylvania State College of Medicine. She is passionate about women’s health, women’s advocacy in surgery, and she is an aspiring breast surgeon.
Christy Teal, MD is the Director of the Breast Care Center and Chief of Breast Surgery for The George Washington University Medical Faculty Associates, as well as an Associate Professor of Surgery. Since joining the faculty at GW in 2001, Dr. Teal and her colleagues have developed a cutting-edge, holistic, patient-focused Breast Care Center that integrates complementary medicine with the latest technology and surgical innovations. She is dedicated to performing clinical and translational research with the goal of improving patient outcomes. She has a special interest in taking care of breast cancer patients and those at increased risk for it. Dr. Teal is a Washingtonian Top Doctor, a US News & World Report Top Doctor, a Castle Top Doctor, and is a Fellow of the American College of Surgeons.