In this issue of American Journal of Hematology/Oncology, the feature on contralateral prophylactic mastectomy serves as a bellwether for an interesting shift in practice patterns and patient preferences. After years of efforts to refine less-aggressive surgery, and to prove that breast-conserving surgery could lead to equivalent outcome with radia-tion therapy and appropriate patients selection, we are now seeing clear trends for increased use not only of mastectomy, but also of contralater-al prophylactic mastectomy (CPM).The factors driving escalating rates of CPM are unclear, but are likely to be multifactorial, and may be a different set of considerations for each patients. Factors that have been cited include the increased use of magnetic resonance imaging and resultant equivocal findings, the falsely (in most cases) heightened perception of improvements in outcome, concerns about family history and genetic predisposition, cosmetic considerations, the increasing societal acceptance of mastecto-my, and the wish to avoid the need for ongoing surveillance with breast imaging as well as the anxiety of awaiting results with each test.
It is also possible that both the patient and caregivers are not fully aware of the higher short- and long-term complications of more extensive surgery—not only a higher rate of post-operative infections and seroma, but also longer rehabilitation and most importantly, chronic pain/post-mastectomy syndrome, which approaches 50% in some series.1-4
It will be important going forward to involve all stakeholders in developing educational material that is evidence-based, as well as personalized to different situations, in order to provide both physicians and patients with the best possible decision support through weighing the pros and cons of this important decision.
References
- Vilholm OJ, Cold S, Rasmussen L, et al. The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer. Br J Cancer. 2008;99(4):604-610. doi: 10.1038/sj.bjc.6604534.
- Gärtner R, Jensen MB, Nielsen J, et al. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302(18):1985-1992. doi: 10.1001/jama.2009.1568.
- Bruce J, Thornton AJ, Scott NW, et al. Chronic preoperative pain and psychological robustness predict acute postoperative pain outcomes after surgery for breast cancer. Br J Cancer. 2012;107(6):937-946. doi: 10.1038/bjc.2012.341.
- Bruce J, Thornton AJ, Powell R, et al. Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: a population-based cohort study. Pain. 2014;155(2):232-243. doi: 10.1016/j.pain.2013.09.028.
