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. 2017 Jul 1;152(7):658-664.
doi: 10.1001/jamasurg.2017.0458.

Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer

Steven J Katz  1 , Nancy K Janz  2 , Paul Abrahamse  3 , Lauren P Wallner  3 , Sarah T Hawley  4 , Lawrence C An  3 , Kevin C Ward  5 , Ann S Hamilton  6 , Monica Morrow  7 , Reshma Jagsi  8
Affiliations

Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer

Steven J Katz et al. JAMA Surg. .

Abstract

Importance: Guidelines assert that contralateral prophylactic mastectomy (CPM) should be discouraged in patients without an elevated risk for a second primary breast cancer. However, little is known about the impact of surgeons discouraging CPM on patient care satisfaction or decisions to seek treatment from another clinician.

Objective: To examine the association between patient report of first-surgeon recommendation against CPM and the extent of discussion about it with 3 outcomes: patient satisfaction with surgery decisions, receipt of a second opinion, and receipt of surgery by a second surgeon.

Design, setting, and participants: This population-based survey study was conducted in Georgia and California. We identified 3880 women with stages 0 to II breast cancer treated in 2013-2014 through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery (71% response rate, n = 2578). In this analysis conducted from February to May 2016, we included patients with unilateral breast cancer who considered CPM (n = 1140). Patients were selected between July 2013 and September 2014.

Main outcomes and measures: We examined report of surgeon recommendations, level of discussion about CPM, satisfaction with surgical decision making, receipt of second surgical opinion, and surgery from a second surgeon.

Results: The mean (SD) age of patients included in this study was 56 (10.6) years. About one-quarter of patients (26.7%; n = 304) reported that their first surgeon recommended against CPM and 30.1% (n = 343) reported no substantial discussion about CPM. Dissatisfaction with surgery decision was uncommon (7.6%; n = 130), controlling for clinical and demographic characteristics. One-fifth of patients (20.6%; n = 304) had a second opinion about surgical options and 9.8% (n = 158) had surgery performed by a second surgeon. Dissatisfaction was very low (3.9%; n = 42) among patients who reported that their surgeon did not recommend against CPM but discussed it. Dissatisfaction was substantively higher for those whose surgeon recommended against CPM with no substantive discussion (14.5%; n = 37). Women who received a recommendation against CPM were not more likely to seek a second opinion (17.1% among patients with recommendation against CPM vs 15.1% of others; P = .52) nor to receive surgery by a second surgeon (7.9% among patients with recommendation against CPM vs 8.3% of others; P = .88).

Conclusions and relevance: Most patients are satisfied with surgical decision making. First-surgeon recommendation against CPM does not appear to substantively increase patient dissatisfaction, use of second opinions, or loss of the patient to a second surgeon.

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Figures

Figure 1
Figure 1. Correlates of surgeon recommendation against contralateral prophylactic mastectomy
Odds ratios (95% confidence intervals) from a logistic regression model using multiple imputation for missing data and weights for differing probabilities of sample selection and non-response. Ref indicates reference group; Dx indicates diagnosis; LA indicates Los Angeles County.
Figure 2
Figure 2. Dissatisfaction with surgical decision by surgeon recommendation and extent of discussion about contralateral prophylactic mastectomy
*Predicted probabilities of surgical decision dissatisfaction. Rates are marginal predictions derived from a multivariable logistic model, averaging over marital status, education, insurance, race, employment, stage, risk of recurrence, site, and consideration for CPM. **Weighted to account for oversampled groups in the design and non-response
Figure 3
Figure 3. Receipt of second opinion or surgery by second surgeon by surgeon recommendation
* Predicted probabilities of second opinion and surgery by second surgeon. Rates are marginal predictions derived from a multivariable logistic model, averaging over marital status, education, insurance, race, employment, stage, risk of recurrence, site, and consideration for CPM. **Weighted to account for oversampled groups in the design and non-response
See this image and copyright information in PMC

References

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