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Communication as the Key to Breast Conservation.

We have seen a surge in contralateral prophylactic mastectomy (CPM) despite data demonstrating no survival advantage for average-risk women.1,2 This is often driven by patient preferences and their (incorrect) belief that CPM improves outcomes.3 Surgeons exert a significant influence on our patients’ final surgical decisions, educating women eligible for breast-conserving therapy (BCT) on various treatment options, one of which is mastectomy with CPM. Do we convey our individual biases, separate from the patient at hand, along with the facts? The answer is yes. Katz et al4 surveyed women with early-stage breast cancer and their surgeons to quantitate the influence that the surgeon had on rates of CPM. Their analysis revealed that at least 20% of the variation in CPM rates could be directly linked to the individual surgeon: the estimated rate of CPM was only 4% for surgeons who most favored BCT and were most reluctant to perform CPM vs 34% for surgeons who least favored BCT and were least reluctant to perform CPM. This study does not examine why surgeons differ in their willingness to offer CPM, but the reasons to offer CPM cited most frequently by all surgeons surveyed included “to give patients peace of mind” and “avoid patient conflict.”4 It is our opinion that variability in communication and the lack of tools and resources to guide the surgical discussion have created disparate patient experiences. When a patient has a preexisting desire for CPM, we need to dispel the potential myths surrounding her reflexive decision and ensure that she fully understands the risks and benefits (and lack of survival benefit). Patients who are provided education tools regarding the decision between BCT and mastectomy are more likely to opt for BCT.5 However, this discussion is arduous and timeconsuming. We offer decision-making autonomy to patients, but, in creating that autonomy, we have resigned to overtreatment, motivated by the desire to avoid creating conflict in our relationship with the patient. How do we overcome this hurdle? Consensus statements reinforce that CPM should be discouraged in averagerisk patients,6,7 but it is time to move beyond consensus statements and create communication tools that guide the surgeon and patient through a stepwise informed discussion. We are participating in a multi-institutional randomized trial to develop such an aid, and we believe this will effect real change in the way surgeons counsel patients. The goal is to standardize the methods and information patients receive to ensure that their decisions are based on facts, not fear.