Bilateral mastectomy – overtreatment?

This week’s radiation oncology (#radonc) twitter journal club featured the recent paper (http://www.ncbi.nlm.nih.gov/pubmed/25182099) that, in part, showed an increase in the rate of bilateral mastectomy (BLM) for early stage breast cancer from 2% in 1998 to 12.3% in 2011. Broken down by age group, over 35% of women under 40 years old, 20% aged 40-49, and 10% of women 50-64 are now getting bilateral mastectomy when a unilateral lumpectomy and radiation is a viable alternative.

I was quite taken aback when I heard those numbers, especially once learning that the same study showed absolutely no survival difference between BLM and lumpectomy. Is this overtreatment gone overboard? It is not shocking to learn that those most likely to get BLM were white, affluent, and had private insurance. And while pursuing BLM is a sensitive topic particularly when genetic mutations and strong family histories are involved, the medical community needs to take a step back to consider the current state of affairs.

Some of the patients getting now getting BLM (12% of *all* early stage breast cancers!) do so because they are demanding it of their surgical oncologists in order to ease their anxiety regarding a potential second breast cancer down the road. And surgeons are increasingly agreeing in order to “satisfy” their patients, creating a “new normal” where overtreatment with BLM is acceptable. Since when is major surgery an acceptable answer to dealing with patients’ anxiety? If a major celebrity were to get thyroid cancer, and the public were to learn that the prevalence of occult thyroid cancer is 5-30% from autopsy studies (http://www.ncbi.nlm.nih.gov/pubmed/23517343), would prophylactic thyroidectomies become an accepted practice?

We also now know that the most highly “satisfied” patients cost more to the healthcare system and are more likely to die compared to less “satisfied” patients (http://www.ncbi.nlm.nih.gov/pubmed/22331982). I have written about this (http://www.cmaj.ca/content/early/2013/08/12/cmaj.130366.full.pdf+html) before, but physicians need to be very careful in separating what patients want from what’s best for patients, because these two concepts can sometimes be at odds with each other. This is reflected in the fact that most patients are highly satisfied with their choice of BLM after their surgery despite having a worse body image, sexual function, and substantially more repeat operations and major complications (see Discussion in article linked to in the first paragraph).

I am not arguing that BLM is inappropriate for all women diagnosed with breast cancer. But the high rate and exponential growth in the rate of BLM over time causes me great concern. Currently the most high profile debate in breast cancer is regarding the value of screening mammography; however, I think more attention needs to be paid to the overtreatment of early stage disease.