Lim David W, Metcalfe Kelly A, Narod Steven A
Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
JAMA Surg. 2021 Jun 1;156(6):569-576. doi: 10.1001/jamasurg.2020.6664.
Rates of bilateral mastectomy continue to increase in average-risk women with unilateral in situ and invasive breast cancer. Contralateral prophylactic mastectomy rates increased from 5% to 12% of all operations for breast cancer in the US from 2004 to 2012. Among women having mastectomy, rates of contralateral prophylactic mastectomy have increased from less than 2% in 1998 to 30% in 2012.
The increased use of breast magnetic resonance imaging and genetic testing has marginally increased the number of candidates for bilateral mastectomy. Most bilateral mastectomies are performed on women who are at no special risk for contralateral cancer. The true risk of contralateral breast cancer is not associated with the decision for contralateral prophylactic mastectomy; rather, the clinical factors associated with the probability of distant recurrence are associated with bilateral mastectomy. Several changes in society and health care delivery appear to act concurrently and synergistically. First, the anxiety engendered by a fear of cancer recurrence is focused on the contralateral cancer because this is most easily conceptualized and provides a ready target that can be acted upon. Second, the modern woman with breast cancer is supported by the surgeon and the social community of breast cancer survivors. Surgeons want to respect patient autonomy, despite guidelines discouraging bilateral mastectomy, and most women have their expenses covered by a third-party payer. Satisfaction with the results is high, but the association with improved psychosocial well-being remains to be fully understood.
Reducing the use of medically unnecessary contralateral prophylactic mastectomy in women with nonhereditary, unilateral breast cancer requires a social change that addresses patient-, physician-, cultural-, and systems-level enabling factors. Such a transformation begins with educating clinicians and patients. The concerns of women who want preventive contralateral mastectomy must be explored, and women need to be informed of the anticipated benefits (or lack thereof) and risks. Areas requiring further study are considered.
在患有单侧原位癌和浸润性乳腺癌的平均风险女性中，双侧乳房切除术的比率持续上升。在美国，2004年至2012年期间，对侧预防性乳房切除术的比率从所有乳腺癌手术的5%增至12%。在接受乳房切除术的女性中，对侧预防性乳房切除术的比率从1998年的不到2%增至2012年的30%。
乳房磁共振成像和基因检测使用的增加略微增加了双侧乳房切除术的候选人数。大多数双侧乳房切除术是在对侧癌症无特殊风险的女性身上进行的。对侧乳腺癌的真正风险与对侧预防性乳房切除术的决策无关；相反，与远处复发可能性相关的临床因素与双侧乳房切除术相关。社会和医疗保健服务方面的若干变化似乎同时并协同发挥作用。首先，对癌症复发的恐惧所引发的焦虑集中在对侧癌症上，因为这最容易理解，并且提供了一个可以采取行动的现成目标。其次，患有乳腺癌的现代女性得到外科医生和乳腺癌幸存者社会群体的支持。尽管指南不鼓励双侧乳房切除术，但外科医生希望尊重患者的自主权，而且大多数女性的费用由第三方支付者承担。对结果的满意度很高，但与改善心理社会幸福感之间的关联仍有待充分了解。
减少非遗传性单侧乳腺癌女性中不必要的对侧预防性乳房切除术的使用需要进行社会变革，以解决患者、医生、文化和系统层面的促成因素。这种转变始于对临床医生和患者的教育。必须探究希望进行预防性对侧乳房切除术的女性的担忧，并且需要告知女性预期的益处（或缺乏益处）和风险。文中考虑了需要进一步研究的领域。
