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Contralateral prophylactic mastectomies. Not helping. No one seems to care. This is Healthcare Triage News.

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Contralateral prophylactic mastectomies.  Not helping.  No one seems to care.  This is Healthcare Triage News.

(Intro)

Two years ago on my blog, I discussed a study entitled "Social and clinical determinants of contralateral prophylactic mastectory."  This was a study looking at women who had breast cancer and then had to decide whether to remove their other breast prophylactically.  It's important to understand that most women don't need that procedure.  The Society of Surgical Oncology says it should only be considered in women who have a genetic mutation, like a BRCA gene mutation or a family history of at least two first degree relatives with breast or ovarian cancer.

This study found, however, that 69% of the women who had the procedure performed had neither of these risk factors.  A Cochrane Review of the procedure found that it does not improve survival in women without these risk factors.  The vast majority of women who underwent a prophylactic mastectomy would likely receive no benefit at all.  

It gets worse.  Women who had an MRI were significantly more likely to have the procedure, even when the MRI showed nothing was wrong with their other breast.  New technology is increasing the rate of unnecessary procedures, not improving it.

With respect to breast cancer, we seem willing to tolerate an incredibly high rate of unnecessary surgery even when we know that that surgery won't do any good.  Everything seems to be going in the wrong direction.  Women who have this surgery have complications, almost half of women who have reconstruction with this procedure require an unanticipated reoperation in the future.  In essence, many women are accepting a real risk of future problems while trying to prevent a phantom one.

I bring this up because this week, there's a new study in Annals of Surgery, "Growing Use of Contralateral Prophylactic Mastectomy despite no improvement in long term survival for invasive breast cancer."  Again, women keep on choosing to have their non-worrisome breast removed in an effort to prolong life and prevent breast cancer occurence.  This is in spite of evidence showing it does no good. 

This study used SEER data to examine trends in that behavior.   They identified about half a million women diagnosed with unilateral invasive breast cancer.  About 60% of them had breast conserving surgery, about a third had unilateral mastectomy, leaving about 7% choosing a contralateral prophylactic mastectomy, but that number increased not decreased over time.  In 2002 about 4% of women chose that route.  In 2012, almost 13% chose it.  Women who choose contralateral prophylactic mastectomy need more surgery in general.  About half of such women also get reconstructive surgery, compared to 16% of those who undergo a unilateral mastectomy.

Here's the kicker though.  With half a million patients available for analysis, they could find no benefit in breast cancer specific survival or overall survival, even after taking into account hormone receptor status or age.  For those of you keeping track at home, in the fully adjusted analyses, the hazard ratios for contralateral prophylactic mastectomy were actually significantly worse compared to breast conservation surgery.  Breast cancer-specific survival had a rate of 1.08 and overall survival had a ratio of 1.08 as well.

Worse!  What are we doing?

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