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Supporting Patient Decision Making in Breast Cancer Surgery—Commentary

Commentary
10/18/2018 Mary Ann Kosir, MD, Wayne State University School of Medicine|Barbara Ann Karmanos Cancer Institute;

Surgical treatments for breast cancer have existed since the 19th century. Radical mastectomy was pioneered by William Halsted in the 1880s and removes all breast tissue as well as the pectoralis muscles and axillary lymph nodes. It was the prevailing surgical treatment for decades. This approach, while decreasing breast cancer recurrence, was massively disfiguring and caused many complications.

In the mid-20th century, doctors developed less extensive surgeries such as the modified radical mastectomy (in which the pectoralis muscle is not removed) and breast-conserving surgery (also known as lumpectomy or quadrantectomy). In the 1980s, 100 years after Halsted popularized the radical mastectomy, landmark trials (1, 2) showed that lumpectomy combined with radiation had similar survival rates as mastectomy, but with fewer complications.

Other advances in management of breast cancer have resulted in several additional therapies being indicated for certain patient subgroups, including

  • Chemotherapy
  • Hormonal agents
  • Radiation therapy

In addition, patients now have various surgical options:

  • For mastectomy: skin-sparing, nipple-sparing, simple, modified radical
  • Axillary node dissection vs sentinel node biopsy
  • Cosmetic reconstruction timing and options
  • Chemotherapy before surgery (neoadjuvant)

The complexity of these various surgical and medical options in breast cancer treatment has created new challenges in patient decision making, especially with regard to surgical therapy. For example, despite well-established guidelines that breast-conserving surgery is equivalent to mastectomy for patients with early breast cancer, use of mastectomy is increasing in the US (3).

Reasons for this increase are unclear but could be related to provider or patient preference or to patient misconceptions about the role of surgery in breast cancer. Patients may struggle to access the most up-to-date information and may cling to misconceptions that could hinder effective surgical treatment. Therefore, providers play a crucial role in helping patients understand treatment options and guiding the complex decision making process.

Clarifying Patient Misconceptions

Breast cancer specialists encounter several common misconceptions:

Removal of breast is best. Some patients, not illogically, assume that the more tissue that is removed the better the likelihood of removing all the cancer. In reality, survival and recurrence rates are generally equivalent between mastectomy and breast conserving surgery with radiation treatment. The issue is that invasive breast cancer is a systemic disease.

Chemotherapy and radiation therapy are not necessary if they get a mastectomy. Physicians need to educate patients that radiation therapy and chemotherapy are both often necessary even when a mastectomy is done.

Radiation therapy does not affect the appearance of the breast. In fact, radiation can cause some discoloration and/or disfiguration.

Double mastectomy is better because the cancer may come back in the other breast. Unless the patient’s genetic factors indicate high risk, a double mastectomy simply means double the complications and recovery time.

Supporting Better Patient Decisions

The most important method of ensuring appropriate patient decision-making is good and ongoing communication between the patient and a multi-modality cancer team. The patient should have access to a multidisciplinary team including medical and radiation oncologists and surgeons to determine a course of action. In addition, it is important to involve a plastic surgeon early in the process. In many cases, using photos and showing the patient the impact of various treatments in a mirror can help them decide what they’re comfortable with

Physicians can also direct patients to online information resources on breast cancer surgery, including the American Cancer Society, Susan G. Komen, and the National Cancer Institute. The Manuals consumer page on breast cancer is another valuable patient resource.

Various patient decision aids also are available and have been shown beneficial by recent research (4-8). Decision aids can be in the form of

  • Patient pamphlets
  • Patient education classes
  • Audiobooklets
  • Interactive websites

Decision aids can help patients clarify their values and understand the trade-offs among different surgical and medical options. For example, a decision aid may help a woman who is extremely anxious about risk of recurrence understand that she might prefer a mastectomy over breast-conserving surgery. 

The main problem with decision aids is that they are generic and become outdated very quickly. In contrast, a provider’s conversation with a patient incorporates the patient’s specific diagnosis and the most up-to-date research, clinical trials, and treatment options. However, with technology advances, an app or other continuously updated tool may one day be better equipped to address factors specific to every patient.

Ultimately, in-depth and ongoing communication with a cancer care team is the best way to ensure the most effective surgical plan. Surgical treatment options for breast cancer are complex, and an individualized approach to each patient is essential.

 

References

1. Fisher B, Redmond C, Fisher ER, et al: Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312:674–681,1985. DOI:10.1056/NEJM198503143121102

2. Fisher B, Bauer M, Margolese R, et al: Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 312:665–673, 1985. DOI:10.1056/NEJM198503143121101

3. Kummerow KL, Du L, Penson DF, et al: Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg 50(1):9–16, 2015. DOI:10.1001/jamasurg.2014.2895

4. Hawley ST, Newman L, Griggs JJ, et al: Evaluating a decision aid for improving decision making in patients with early stage breast cancer. Patient. 9(2):161–169, 2016. DOI:10.1007/s40271-015-0135-y 

5. Whelan T, Levine M, Willan A, et al: Effect of a decision aid on knowledge and treatment decision making for breast cancer surgery: a randomized trial. JAMA 292(4):435–441, 2004.

6. Goel V, Sawka CA, Thiel EC, et al: Randomized trial of a patient decision aid for choice of surgical treatment for breast cancer. Med Decis Making 21(1):1–6, 2001.

7. Molenaar S, Sprangers MA, Rutgers EJ, et al: Decision support for patients with early-stage breast cancer: effects of an interactive breast cancer CDROM on treatment decision, satisfaction, and quality of life. J Clin Oncol 19(6):1676–1687, 2001.

8. Jibaja-Wess M, Volk RJ, Granchi TS, et al: Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy. Patient Educ Couns  84(1):41–48, 2011.