‘Taking Control of Cancer’: Understanding Women’s Choice for Mastectomy
- 1k Downloads
Rates of both unilateral (UM) and contralateral prophylactic mastectomy (CPM) for unilateral early-stage breast cancer (ESBC) have been increasing since 2003. Recent studies suggest that this increase may be due to women choosing UM and CPM because of fear. We conducted an in-depth qualitative study to identify those factors influencing a woman’s choice for more extensive surgery.
Semi-structured interviews were conducted with breast cancer patients to examine the experiences, decision making, and choice of UM ± CPM for the treatment of ESBC. Purposive sampling identified suitable candidates for breast-conserving therapy (BCT) who underwent UM ± CPM. Interviews were guided by grounded theory methodology, and constant comparative analysis identified key concepts and themes.
Data saturation was achieved after 29 interviews. ‘Taking control of cancer’ was the dominant theme. Fear of breast cancer was expressed at diagnosis and remained throughout decision making. Personal experiences of family or friends ‘living with cancer’ were the most influential source of information during the decision-making process. Fear translated into an overestimated risk of recurrence, contralateral breast cancer (CBC), and death. Despite surgeons discussing equivalent survival with BCT, UM ± CPM patients believed that by choosing UM ± CPM they would eliminate recurrence, CBC and live longer. By choosing more extensive surgery, women were actively trying to control cancer outcomes as more surgery was believed to offer greater survival.
Women seek UM and CPM to take control of cancer and manage their fear. It is important for surgeons to understand how personal experiences shape women’s choice for UM ± CPM to facilitate informed decision making.
KeywordsNational Comprehensive Cancer Network National Comprehensive Cancer Network Contralateral Breast Cancer Contralateral Prophylactic Mastectomy Experiential Knowledge
With sincere thanks to Dr. M. Aarts, Dr. N. Down, Dr. R. George, and Dr. T. Gillis for their assistance in recruiting study participants. The authors would also like to thank all of the patient participants who offered their time and shared their experiences.
Dr. Covelli received a research fellowship from the Canadian Breast Cancer Foundation – Roche Physician Fellowship Program, and 1 year of salary support from the Clinical Investigator Program – Ontario Ministry of Health salary support program. She also received a travel grant to present work related to this research from the Canadian Institute of Health Research, as well as a Novartis Oncology Young Clinical Investigators Award (NOYCIA) and an ASCO Merit Award for work presented related to this research. The Surgeon Scientist Training Program provided indirect financial support to Dr. Covelli through programs delivered to surgeon scientists in training at the Department of Surgery, University of Toronto. Dr. Baxter holds the Cancer Care Ontario Health Services Research Chair. Dr. McCready receives research support from the Gattuso Chair in Breast Surgical Oncology at Princess Margaret Hospital.
- 1.National Institutes of Health. Treatment of early-stage breast cancer. June 18–21 1990. JAMA. 1991;265:391–5.Google Scholar
- 14.Canadian Institute for Health Information. Breast Cancer Surgery in Canada, 2007–2008 to 2009–2010. In: Dabbs K, Porter G, Wai E, eds. Ottawa: Canadian Institute for Health Information; 2012. https://secure.cihi.ca/free_products/BreastCancer_7-8_9-10_EN.pdf. Accessed 1 June 2014.
- 15.National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: breast cancer risk reduction. Version 1.2014. http://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf. Accessed 26 July 2014.
- 16.National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: high risk assessment: breast and ovarian. Version 1.2014. http://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Accessed 26 July 2014.
- 19.Brennan ME, Houssami N, Lord S, et al. Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: systematic review and meta-analysis of incremental cancer detection and impact on surgical management. J Clin Oncol. 2009;27:5640–9.PubMedCrossRefGoogle Scholar
- 25.Hawley ST, Jagsi R, Morrow M, et al. Social and clinical determinants of contralateral prophylactic mastectomy. JAMA Surg. Epub 21 May 2014.Google Scholar
- 26.National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: breast cancer. National Comprehensive Cancer Network; 2014.Google Scholar
- 29.Charmaz K. Constructing grounded theory. Thousand Oaks: Sage; 2009.Google Scholar
- 33.Kuzel A. Sampling in qualitative inquiry. In: Crabtree B, Miller W, eds. Doing qualitative research. Newbury Park: Sage; 1992. pp. 31–44.Google Scholar
- 34.Charmaz K. Grounded theory in the 21st century. In: Denzin NK, Lincoln YS, eds. Handbook of qualitative research. Thousand Oaks: Sage; 2000.Google Scholar
- 38.d’Agincourt-Canning L. The effect of experiential knowledge on construction of risk perception in hereditary breast/ovarian cancer. J Genet Couns. 2005;14:55–69.Google Scholar
- 39.Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Risky feelings: why a 6 % risk of cancer does not always feel like 6%. Patient Educ Couns. 2010;81(Suppl):S87–93.Google Scholar
- 41.Borgida E, Nisbett RE. The differential impact of abstract vs. concrete information on decisions. J Appl Psychol. 1977;7:258–71.Google Scholar
- 48.Lostumbo L, Carbine NE, Wallace J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev. 2010:(11):CD002748.Google Scholar
- 49.Nichols HB, Berrington de Gonzalez A, Lacey JV Jr, et al. Declining incidence of contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol. 2011;29:1564–9.Google Scholar
- 60.Frost MH, Hoskin TL, Hartmann LC, et al. Contralateral prophylactic mastectomy: long-term consistency of satisfaction and adverse effects and the significance of informed decision-making, quality of life, and personality traits. Ann Surg Oncol. 2011;18:3110–6.PubMedCentralPubMedCrossRefGoogle Scholar