Women's preferences for contralateral prophylactic mastectomy following unilateral breast cancer: What risk-reduction makes it worthwhile?

OBJECTIVES: Contralateral prophylactic mastectomy (CPM) reduces the risk of contralateral breast cancer (BC) following unilateral BC, but may not increase survival in BRCA1/2 mutation negative women. Despite this, and the risk for adverse physical and psychological impact, uptake is increasing in BRCA1/2 mutation negative women. We aimed to quantify the degree of reduction in lifetime contralateral BC risk women required to justify CPM, and to explore demographic, disease and psychosocial predictors of preferences using Protection Motivation Theory (PMT) as a theoretical framework. Reasoning behind preferences was also examined. MATERIALS AND METHODS: 388 women previously diagnosed with unilateral BC, of negative or unknown BRCA1/2 status, were recruited from an advocacy group research database. Two hypothetical risk trade-off scenarios were used to quantify the reduction in lifetime contralateral BC risk that women judged necessary to justify CPM, using a 5% and 20% baseline. Demographic, disease and PMT measures were assessed using a questionnaire. RESULTS: Most women required their risk to be more than halved from a 5% or 20% baseline to justify CPM. Polarised preferences were also common, with some women consistently accepting or refusing CPM independent of risk/benefit trade-offs. Preferences were associated with coping self-efficacy and having a prior CPM. Explanations for judging CPM worthwhile included reducing or eliminating contralateral BC risk, attaining breast symmetry and reducing worry. CONCLUSION: Risk-reduction preferences were highly variable. Decisive factors in women's preferences for CPM related to clinical, psychological and cosmetic outcomes, but not to demographic or disease characteristics.

Women's preferences for contralateral prophylactic mastectomy: An investigation using protection motivation theory.

OBJECTIVE: Most women diagnosed with unilateral breast cancer without BRCA1 or BRCA2 mutations are at low risk of contralateral breast cancer. Contralateral Prophylactic Mastectomy (CPM) decreases the relative risk of contralateral breast cancer, but may not increase life expectancy; yet international uptake is increasing. This study applied protection motivation theory (PMT) to determine factors associated with women's intentions to undergo CPM. METHODS: Three hundred eighty-eight women previously diagnosed with unilateral breast cancer and of negative or unknown BRCA1 or BRCA2 status were recruited from an advocacy group's research database. Participants completed measures of PMT constructs based on a common hypothetical CPM decision-making scenario. RESULTS: PMT constructs explained 16% of variance in intentions to undergo CPM. Response efficacy (CPM's advantages) and response costs (CPM's disadvantages) were unique individual predictors of intentions. CONCLUSION: Decision-making appears driven by considerations of the psychological, cosmetic and emotional advantages and disadvantages of CPM. Overestimations of threat to life from contralateral breast cancer and survival benefit from CPM also appear influential factors. PRACTICE IMPLICATIONS: Patients require balanced and medically accurate information regarding the pros and cons of CPM, survival rates, and recurrence risks to ensure realistic and informed decision-making.

Predicting women's intentions for contralateral prophylactic mastectomy: An application of an extended theory of planned behaviour.

PURPOSE: Most women with unilateral breast cancer (BC) without BRCA1/2 gene mutations are at low risk of contralateral breast cancer (CBC). One CBC risk-management option is contralateral prophylactic mastectomy (CPM). While there is no evidence that CPM increases life-expectancy, its uptake is increasing. This study aimed to assess the validity of an extended social-cognition model, the Theory of Planned Behaviour (TPB), in predicting women's intentions to undergo CPM. METHOD: Four hundred women previously treated for BC completed an online survey exploring demographic and disease factors, attitude, subjective norm, perceived behavioural control, anticipated regret, uncertainty avoidance, self-efficacy to not have CPM and intentions to undergo CPM in a common hypothetical decision-making scenario. RESULTS: The TPB uniquely explained 25.7% of intention variance. Greater anticipated regret, uncertainty avoidance and lower self-efficacy to cope with not having CPM were associated with stronger CPM intentions, explaining an additional 7.7%, 10.6% and 2.9% respectively, of variance over and above the TPB. Women who had undergone CPM, had not attended university, and had children reported stronger CPM intentions. CONCLUSIONS: A holistic understanding of CPM decision-making appears to require consideration beyond CBC risk, demographics and disease characteristics, exploring women's expectations about CPM outcomes, others' opinions, and avoidance of emotionality and difficulties associated with not undergoing surgery. This study provides a theoretical basis from which the complexity of CPM decision-making may be understood, and from which resources for patients and treating staff may be developed to support women's informed decision-making aligning with their personal values.

Follow up after breast cancer -- views of Australian women.

BACKGROUND: Survivorship care after breast cancer treatment is increasingly complex as it aims to manage the long term effects of cancer and its treatment, including psychosocial needs. While survivorship care is traditionally delivered by surgeons and specialist oncologists in Australia, general practitioners are ideally placed to manage these issues. METHODS: This study explored the attitudes of 20 breast cancer survivors to GP involvement in follow up care through semi-structured telephone interviews, which were analysed using qualitative methods. RESULTS: Women were reluctant to change from specialist based care but identified many potential benefits of GP involvement in long term cancer care. They expressed an interest in shared care programs between specialists and GPs. Some participants thought that additional training may be required if GPs were to deliver this care. CONCLUSION: This study shows cautious interest from breast cancer survivors for increasing GP involvement in follow up care. These views should be considered as alternative models of care are developed.

Survivorship care after breast cancer treatment--experiences and preferences of Australian women.

Follow-up care after breast cancer treatment is becoming more complex as it attempts to address the long-term needs of an increasing number of survivors. Workforce issues in oncology challenge the sustainability of current specialist-based care. This study explores survivors' experiences with follow-up care and attitudes to alternative models including a tailored survivorship care plan and involvement of primary care physicians and breast care nurses. Twenty women across Australia participated in semi-structured telephone interviews. All continued to attend follow-up visits with a specialist oncologist and reported a high level of satisfaction with care. Participants described a strong reliance on their specialist but were open to an increased role for their primary care physician in a shared model of care. Communication between multidisciplinary team members was perceived as an ongoing problem and there was enthusiasm for a patient-held written survivorship care plan to address this, and to meet information needs.