Impact of age, rurality and distance in predicting contralateral prophylactic mastectomy for breast cancer in a Midwestern state: a population-based study.
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ABSTRACT: Purpose
Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women < 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns.Methods
Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (MTD) were compared. Characteristics associated with CPM were evaluated with multivariate logistic regression.Results
22,158 women were identified: 57% metro, 26% nonmetro and 18% rural. Young rural women had the highest proportion of CPM (52%, 39% and 40% for rural, metro, nonmetro women < 40 years). Half of all rural women had surgery at metro hospitals; these women had the longest MTD (62 miles). Among all women treated at metro hospitals, rural women had the highest proportion of CPM (17% rural vs 14% metro/nonmetro, p = 0.007). On multivariate analysis, traveling ≥ 50 miles (ORs 1.43-2.34) and rural residence (OR = 1.29) were independently predictive of CPM. Other risk factors were young age (< 40 years: OR = 7.28, 95% CI 5.97-8.88) and surgery at a metro hospital that offers reconstruction (OR = 2.30, 95% CI 1.65-3.21) and is not NCI-designated (OR = 2.34, 95% CI 1.92-2.86).Conclusion
There is an unexpectedly high proportion of CPM in young rural women in Iowa, and travel distance and availability of reconstructive services likely influence decision-making. Improving access to multidisciplinary care in rural states may help optimize decision-making.
SUBMITTER: Lizarraga IM
PROVIDER: S-EPMC8238858 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:PurposeDespite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.MethodsWomen diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.ResultsBoth rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).ConclusionThe impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.
| S-EPMC10689552 | biostudies-literature
Project description:BackgroundAn increasing number of patients undergo contralateral prophylactic mastectomy (CPM) for unilateral breast cancer. However, the benefit of CPM has not been quantified in the setting of contemporary breast cancer therapy.MethodsWe performed an analysis of 180 068 patients in the Surveillance, Epidemiology, and End Results (SEER) database, diagnosed with unilateral ductal breast carcinoma between 1998 and 2013 and treated with unilateral mastectomy (UM) or CPM. UM was performed in 146 213 patients (81.2%); CPM was performed in 33 855 patients (19.8%). Primary outcome of interest was cumulative incidence of a second primary breast cancer in the ipsilateral or contralateral breast greater than 3 months after initial diagnosis. Cumulative incidence analysis was based on a Cox proportional model to generate curves of second primary breast cancer in any breast, ipsilateral breast only, or contralateral breast only.ResultsPatients who underwent CPM had a significantly reduced incidence of second primary breast cancer 10 and 15 years after surgery (CPM 0.93% [0.73%, 1.12%] vs UM 4.44% [4.28%, 4.60%]). Patients who underwent CPM had significantly lower adjusted hazard of second primary breast cancer when compared with UM (HR 0.38 vs 1.0, P < .0001).ConclusionsCPM offers some protection from a second primary breast cancer, attributable to a reduced incidence in the contralateral breast. These findings provide additional information to providers and patients as they make decisions regarding surgical management. They should also be interpreted in the context of the absolute incidence of second primary breast cancer after UM and previous literature demonstrating no survival benefit.
| S-EPMC7643660 | biostudies-literature
Project description:OBJECTIVES:The study's goals were to characterize decisional conflict and preparedness for making the decision about having CPM among breast cancer patients considering CPM who do not carry cancer-predisposing mutation and to evaluate correlates of decisional conflict and preparedness. METHODS:93 women considering CPM completed a survey of decisional conflict and preparedness for the CPM decision, knowledge, perceived risk, self-efficacy, reasons for CPM, input from others and discussion with the doctor about CPM, and cancer worry. RESULTS:Between 8% and 27% of women endorsed elevated decisional conflict. Most women were satisfied with preparatory information that they were provided. Knowledge was low. Top reasons for choosing CPM were the desire for peace of mind, lowering the chance of another breast cancer, and improving survival. CONCLUSIONS:Decisional conflict is elevated in a subset of patients considering CPM. A more well-informed decision may be fostered by a comprehensive discussion about CPM with the patient's clinician, fostering self-efficacy in managing cancer worry, and helping patients understand their motivations for CPM. PRACTICE IMPLICATIONS:Clinicians working with breast cancer patients considering CPM should discuss the CPM decision, foster self-efficacy in managing cancer worry, and help patients understand their motivations for the surgery.
| S-EPMC7666877 | biostudies-literature
Project description:BACKGROUND:Contralateral prophylactic mastectomy may be unnecessary from an oncologic perspective; therefore, the debate persists about the value of contralateral prophylactic mastectomy in women with early-stage unilateral breast cancer. Given finite health care resources, this study aims to evaluate the cost of contralateral prophylactic mastectomy and breast reconstruction. METHODS:Women with unilateral breast cancer undergoing either unilateral mastectomy or unilateral mastectomy with contralateral prophylactic mastectomy and immediate breast reconstruction were selected from the Truven MarketScan databases between 2009 and 2013. Demographic and treatment data were recorded, and over an 18-month follow-up period, the treatment cost was tallied. A log-transformed linear model was used to compare cost between the groups. RESULTS:A total of 2343 women were identified who met our inclusion criteria, with 1295 undergoing unilateral mastectomy and 1048 undergoing contralateral prophylactic mastectomy. Complication rates within 18 months were similar for women undergoing unilateral mastectomy and contralateral prophylactic mastectomy (39 percent versus 42 percent; p = 0.17). Management with unilateral mastectomy with reconstruction required an adjusted cumulative mean cost of $33,557. Contralateral prophylactic mastectomy with reconstruction was an additional $11,872 in expenditure (p < 0.001). The cost of initial procedures (mean difference, $6467) and secondary procedures (mean difference, $2455) were the greatest contributors to cost. CONCLUSIONS:In women with unilateral breast cancer, contralateral prophylactic mastectomy with reconstruction is more costly. The increased monetary cost of contralateral prophylactic mastectomy may be offset by improved quality of life. However, this financial reality is an important consideration when ongoing efforts toward reimbursement reform may not pay for contralateral prophylactic mastectomy if outcomes data are not presented to justify this procedure.
| S-EPMC5922428 | biostudies-literature
Project description:BACKGROUND AND OBJECTIVES:Women with unilateral early-stage breast cancer are increasingly choosing contralateral prophylactic mastectomy (CPM) despite the absence of survival benefits and increased risk of surgical complications. Data are lacking on whether this trend extends to women with clinically locally advanced nonmetastatic (cT4M0) cancer. This study aims to estimate national CPM trends in women with unilateral cT4M0 breast cancer. METHODS:Women aged???18 years, who underwent mastectomy during 2004 to 2014 for unilateral cT4M0 breast cancer were identified using the National Cancer Database and grouped as all locally advanced (T4), chest wall invasion, skin nodule/ulceration, or both (T4abc), and inflammatory (T4d) cancer. Poisson regression for trends and logistic modeling for predictors of CPM were performed. RESULTS:Of 23 943 women, 41% had T4abc disease and 35% T4d. Cumulative CPM rates were 15%, 23%, and 18%, for the T4abc, T4d, and all T4 groups, respectively. Trend analysis revealed a significant upsurge in CPM demonstrating 12% annual growth for T4abc tumors, 8% for T4d and 9% for all T4 (all P?<?0.001). CONCLUSIONS:Increasing numbers of women with unilateral cT4M0 breast cancer are undergoing CPM. This rising trend warrants further research to understand stakeholders' preferences in surgical decision-making for women with locally advanced breast cancer.
| S-EPMC6327316 | biostudies-literature
Project description:BackgroundRates of contralateral prophylactic mastectomy (CPM)-removal of the healthy breast following breast cancer diagnosis-have increased, particularly among women for whom CPM provides no survival benefit. Affective (i.e., emotional) decision making is often blamed for this increase. We studied whether greater negative breast cancer affect could motivate uptake of CPM through increased cancer risk perceptions and biased treatment evaluations.MethodsWe randomly assigned healthy women with average breast-cancer risk (N = 1030; Mage = 44.14, SD = 9.23 y) to 1 of 3 affect conditions (negative v. neutral v. positive narrative manipulation) in a hypothetical online experiment in which they were asked to imagine being diagnosed with cancer in one breast. We assessed 1) treatment choice, 2) affect toward CPM, and 3) perceived risk of future breast cancer in each breast (cancer affected and healthy) following lumpectomy, single mastectomy, and CPM.ResultsThe manipulation caused women in the negative and neutral narrative conditions (26.9% and 26.4%, respectively) to choose CPM more compared with the positive narrative condition (19.1%). Across conditions, women's CPM affect did not differ. However, exploratory analyses addressing a possible association of affect toward cancer-related targets suggested that women in the negative narrative condition may have felt more positively toward CPM than women in the positive narrative condition. The manipulation did not have significant effects on breast cancer risk perceptions.LimitationsThe manipulation of affect had a small effect size, possibly due to the hypothetical nature of this study and/or strong a priori knowledge and attitudes about breast cancer and its treatment options.ConclusionIncreased negative affect toward breast cancer increased choice of CPM over other surgical options and might have motivated more positive affective evaluations of CPM.HighlightsThis study used narratives to elicit different levels of negative integral affect toward breast cancer to investigate the effects of affect on breast cancer treatment choices.Increased negative affect toward breast cancer increased the choice of double mastectomy over lumpectomy and single mastectomy to treat a hypothetical, early-stage cancer.The narrative manipulation of negative affect toward breast cancer did not change the perceived risks of future cancer following any of the surgical interventions.Negative affect toward breast cancer may have biased affective evaluations of double mastectomy.
| S-EPMC9898882 | biostudies-literature
Project description:BackgroundThe use of contralateral prophylactic mastectomy (CPM) has increased over the last two decades with variations in the frequency of reconstruction. The objective of this cohort study is to elucidate the use of CPM and reconstruction among underrepresented racial and ethnic groups and women over 65 years.MethodsWomen over 18 years, diagnosed with stages I to III breast cancer who underwent mastectomy from 2004-2017 were identified in the National Cancer Database (NCDB) and grouped into CPM vs. non-CPM. Multivariable analyses were used to examine the associations between CPM and reconstruction with sociodemographic and clinical factors.ResultsA total of 571,649 patients were identified. Patients who underwent CPM were under 50 years (45.9%), White (88.4%) and with private insurance (73.5%). On multivariable analysis, women over 65 years [odds ratio (OR): 0.18, P<0.001], non-White (Black, OR: 0.56, P<0.001) and without private insurance (uninsured, OR: 0.50, P<0.001) had decreased odds of CPM. Women over 65 years (OR: 0.11, P<0.001), non-White (Asian/Pacific Islander, OR: 0.58, P<0.001) and without private insurance (Medicaid, OR: 0.41, P<0.001) had decreased odds of reconstruction.ConclusionsNon-White women and women over the age of 65 years were less likely to have CPM or reconstruction than their White counterparts from 2004 to 2017. Research is needed to understand factors impacting decision-making.
| S-EPMC10570976 | biostudies-literature
Project description:The use of contralateral prophylactic mastectomy (CPM) in the U.S. among patients with unilateral invasive breast cancer increased by 150% from 1993 to 2003. Although CPM has been shown to reduce the risk for developing contralateral breast cancer, there is conflicting evidence on whether or not it reduces breast cancer mortality or overall death. The increase in the CPM rate is especially concerning among women with early-stage sporadic breast cancer who have a minimal annual risk for developing contralateral breast cancer, and for many of these women the risk for distant metastatic disease outweighs the risk for contralateral breast cancer. The lack of information about the clinical value of CPM in women with sporadic breast cancer is an important public health problem. This review evaluates current data on the clinical indications for CPM and long-term patient satisfaction and psychosocial outcomes. Gaps in knowledge about the clinical value of CPM, including patient- and physician-related psychosocial factors that influence the decision-making process of CPM among women with sporadic breast cancer, are highlighted.
| S-EPMC3228146 | biostudies-other
Project description:ImportanceGuidelines 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.ObjectiveTo 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 participantsThis 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 measuresWe 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.ResultsThe 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 relevanceMost 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.
| S-EPMC5520628 | biostudies-literature
Project description:BackgroundDue to differences in socioeconomic and cultural backgrounds, the characteristics and prognosis of Asian female patients choosing contralateral prophylactic mastectomy (CPM) are likely to be different from Western patients. To fill the research gap of CPM in Asian populations, this study aims to explore the application trend, survival benefits, decision-making factors, and satisfaction of CPM based on the Chinese patients undergoing CPM.MethodsThe 0-III stage unilateral breast cancer (UBC) patients who received breast surgery in the Chinese PLA General Hospital from 2005 to 2017 were selected. The surgical procedures included simple mastectomy (SM), nipple-sparing mastectomy (NSM), breast conserving surgery (BCS), and CPM. Cox proportional regression analyses and Kaplan-Meier (KM) curve were performed to compare the overall survival (OS) and disease-free survival (DFS) rates between CPM group and unilateral mastectomy (UM) group. Proportional propensity score matching (PSM) with a 1:1 ratio was used to match the two groups and secondary survival analysis was performed. Logistic regression models were used to test predictive factors related to patients' CPM surgical decision-making.ResultsFour thousand two hundred and seventy-six patients were included in the study, with 73 patients receiving CPM, 3,567 receiving SM, 151 receiving NSM, and 485 receiving BCS. CPM surgery was first used in 2007, with a peak application rate of 3.02% in 2016. Three thousand seven hundred and ninety-one patients were included in the survival analysis, with a median follow-up time of 66.60 months. Compared to UM patients, neither the KM survival curve nor Cox regression hazard analyses of CPM showed better OS (P=0.963; P=0.834). After PSM, CPM also did not exhibit significant survival benefits in OS (P=0.335) and DFS (P=0.409). The logistic regression analyses showed that NSM surgery and lower tumor-node-metastasis (TNM) stage were independent factors to promote the CPM decision-making of patients. The CPM group showed high overall satisfaction (84.9%) and relatively low appearance satisfaction (69.9%).ConclusionsCPM was practiced for the first time since 2007 in our hospital. CPM does not provide any OS and DFS benefits compared to UM and the appearance satisfaction procedure was relatively low. Therefore, clinicians should fully communicate with patients before surgery and be more cautious in giving CPM recommendations.
| S-EPMC10788567 | biostudies-literature