During the last decade, the rates of women with a diagnosis of early-stage breast cancer (ESBC) who undergo contralateral prophylactic mastectomy (CPM) have more than doubled in North America.1,2 This phenomenon is observed among non-high-risk patients who are unlikely to gain a survival advantage, yet face increased risks of complications, chronic pain, and decisional regret associated with bilateral mastectomy. Thus, the role of CPM for these patients remains controversial.3,4,5,6 A growing body of research seeks to better understand this paradoxical shift toward more aggressive surgical management.7,8,9,10,11,12

Increased awareness, availability, and advancements in reconstructive procedures are thought to influence a patient’s decision to pursue CPM.2,13 For instance, studies have demonstrated that women with unilateral breast cancer (UBC) were three times more likely to have CPM if they underwent immediate reconstruction,14 and some patients have regarded CPM as an opportunity to improve the appearance of their breasts through bilateral reconstruction.15

Although breast reconstruction is significantly associated with CPM, the plastic surgeons’ perspective has not been well described in the literature. A survey of Maryland surgeons showed differences in practice patterns across physician specialties such that plastic surgeons recommended proportionately more CPMs than their general surgery colleagues.16 It is postulated that the way plastic surgeons view CPM may differ from the way general surgeons view CPM and thus counsel patients in a manner that makes CPM more acceptable to them.16 Nahabedian17 found that one aim of plastic surgeons treating patients with UBC is to obtain optimal symmetry, and that a contralateral operation may be regarded as necessary to achieve this goal.

Previously, CPM decision-making was investigated among general surgeons and patients with ESBC.9,11,12,15 However, this research was unable to provide a complete picture of the decision-making environment because little is known about the opinions and experiences of reconstructive surgeons during their consultations with women considering their treatment options.

Therefore, we performed a qualitative study to explore how plastic surgeons describe their roles in patients’ decision-making processes regarding breast reconstruction with a view toward advancing our understanding of the rise in CPM rates.

Methods

Participants, Sampling, and Recruitment

The study participants included plastic surgeons in active practice who performed breast reconstructive surgery at academic or community hospitals across Ontario, Canada. The potential participants were identified from the Canadian Collaboration of Breast Reconstruction Directory, which is a publically accessible website containing demographic details and contact information for plastic surgeons across the country. Purposive sampling was used to select participants who varied in terms of location, institution type, years in practice, gender, and practice volume.

Eligible Ontario surgeons were mailed a study package, which contained a hand-signed invitation letter, a consent form, and a response form. An email was sent to nonresponders 2 weeks after the initial mail-out, followed by a telephone call to the remaining non-responders 2 weeks after that. Ethics approval for the study was granted through Sunnybrook Health Sciences Centre and University of Toronto Research Ethics Boards.

Data Collection

Data were collected via semi-structured one-on-one telephone interviews. The participants were asked open-ended questions using an interview guide developed for the study (Table 1). The questions were based on content informed by relevant literature combined with expert opinion from breast surgeons. The guide was pilot-tested with four plastic surgeons to refine the questions and prompts. Interviews were conducted by the same investigator (S.S.) to maintain internal consistency. These interviews were audio-recorded and transcribed verbatim. Data collection concluded once saturation was reached, as determined by consensus from three team members (L.G.C., F.C.W., S.S.).

Table 1 Interview guide
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Data Analysis

Data were initially analyzed inductively using a thematic approach.18 An inductive process involves handling data in a “bottom-up” manner by examining the experiences of participants in their own words and identifying themes that are directly linked to the raw data.18,19 Coding was performed by two researchers (F.C.W., S.S.) to increase the range of perspectives brought to the data.

Through input from the investigative team, in conjunction with an iterative process of constant comparison between the developing concepts and findings from the literature, it became clear that the data resonated with the four principles of biomedical ethics: non-maleficence, respect for autonomy, justice, and beneficence.20,21 These principles offer a comprehensive way of thinking about contentious healthcare issues and currently serve as the ethical framework for modern surgical practice in North America.22 At this stage, the analysis transitioned into more of a deductive process, in which these principles were used as the analytic lens through which the data were viewed.

Results

A total of 43 Ontario plastic surgeons were invited to participate in the study. Of these surgeons, 18 agreed to participate, 6 declined (5 no longer performed breast reconstructions, 1 did not have time), and 19 did not respond. Informed consent was obtained from the 18 surgeons who agreed to participate, and data saturation was achieved.

The interviews were conducted between June and December 2017, with a mean interview time of 33 min (range 21–53 min). Of the 18 surgeons, 10 were women, and 56% (10/18) came from academic hospitals, whereas 44% (8/10) worked in community centers. The participants varied with respect to years in practice and practice volume, as indicated by the number of confirmed breast cancer patients consulted per month (Table 2).

Table 2 Summary of demographic details (n = 18)
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Common Findings

Consistent with existing literature, plastic surgeons perceived that a combination of improved reconstructive techniques, a desire for optimal breast symmetry, media influences, as well as anxiety and fear all play important roles in motivating the pursuit of more aggressive surgical management9,23,24,25,26 (Table 3).

Table 3 Common findings
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Thematic Findings

  1. 1.

    Maintaining Non-maleficence

Based on current guidelines,27,28 CPM is not recommended in the setting of ESBC as it does not provide an oncologic benefit yet increases surgical risks and complications. Aligned with the principle of non-maleficence (“do no harm”), the participants expressed trepidation toward non–high-risk patients undergoing CPM and breast reconstruction because this conflicted with their goal to avoid causing undue harm from an additional surgical procedure (Table 4).

Table 4 Main themes with representative quotes
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Subthemes

Deferral to Oncologists

Participants described their role in managing breast cancer patients as being disconnected from oncologic discussions and did not perceive themselves to be directly involved in decision-making for therapeutic cancer care. If patients requested to remove their unaffected breast during the reconstructive consultation, the plastic surgeons would defer to the treating general surgeon, as they are responsible for making the final decision.

Cannot Compromise Cancer Outcomes for Aesthetics

The participants explained that they were not supportive of performing procedures (e.g., nipple-sparing reconstructions) if it meant compromising the cancer operation and outcomes. Similarly, they would not recommend CPM just to achieve a superior aesthetic result and emphasized that reconstructive decisions should be secondary to oncologic considerations.

Referrals and Second Opinions

The plastic surgeons described how they would refer patients for second opinions if they remained insistent upon undergoing a particular reconstruction that they were not a good candidate for or that was recommended against for safety purposes.

Dissuade Patients

Some of the participants indicated that they would explicitly advise patients against CPM and breast reconstruction unless there was a specific medical justification.

  1. 2.

    Supporting Patient Autonomy

In the healthcare context, autonomy describes a patient’s right to make his or her own medical decisions, including the choice to have CPM. Although the participants sought to maintain non-maleficence, they equally demonstrated respect for a patient’s right to self-governance (Table 4).

Subthemes

Self-Advocating

Many of the participants acknowledged that they were comfortable with CPM if patients advocated for themselves. Some described initially discouraging patients but would ultimately agree if they remained determined to pursue CPM after they had been properly informed of the risks and benefits.

Surveillance Stress

The participants explained that they were supportive of CPM and breast reconstruction as a means to mitigate the cycle of anxiety associated with ongoing breast surveillance and possible further biopsies in the contralateral breast following breast cancer surgery.

  1. 3.

    Delivering (Un)Equal Healthcare

The principle of justice refers to the provision of care that is equitable and fair to all29 The participants highlighted issues that illustrate the complex dilemma surrounding the notion of justice as it relates to breast reconstruction within Ontario’s publicly funded healthcare system (Table 4).

Subthemes

Informational Inequities

The participants noted that many patients referred to them would arrive at their appointment seemingly without adequate education concerning the oncologic risks and survivability of their disease, particularly regarding the contralateral side. They explained that this would create friction during their consultation if the patient requested to remove their healthy breast since the plastic surgeon was the first person in their circle of care to recommend against it.

Reconstruction Inaccessibility

Aligned with the principle of justice was the perception that patients across Ontario are not afforded equal access to reconstructive procedures. The participants explained that some women are not offered plastic surgery consultations altogether, while others may be restricted to the options at their nearest institution rather than being referred to another center with reconstructive options that may be more in line with their individual preferences.

Limited Healthcare Resources

The participants also described the impact that restricted healthcare resources can have on breast cancer decision-making. They indicated that limited operating room availability may shape the choice between immediate implant versus autogenous reconstruction, as the latter operation can take from 8 to 12 h. They also perceived that the growing demand for CPM has translated into increased wait times for breast cancer treatment in Ontario.

  1. 4.

    Providing Care to Enhance Well-Being

Reflective of the principle of beneficence (delivering care to enhance well-being), the participants discussed the challenge of wanting patients to avoid unnecessary risks and the desire to contribute to their emotional welfare by supporting requests for CPM and breast reconstruction (Table 4).

Subthemes

The Evidence Could Evolve

Although guidelines recommend against CPM for non–high-risk patients,26,28 some of the plastic surgeons explained that the evidence may not remain static. They would be remorseful if they counselled a woman out of CPM and she subsequently experienced a malignancy in her contralateral breast or was found to be at higher risk for developing one.

Quality of Life

The participants stated that their role throughout the treatment journey is to help improve patients’ self-esteem. Accordingly, they endeavour to perform reconstructions aligned with patient preferences in order to provide optimal quality-of-life outcomes even though the desired procedure may not be recommended from a guideline standpoint.

Empathy for Patients

Many of the participants described empathizing with the anxiety experienced by their patients and indicated that they would want the most aggressive treatment available if faced with a similar diagnosis. Some acknowledged that they felt badly for cancer patients, thus motivating them to provide care that may compromise their initial surgical plan for one that would deliver the greatest peace-of-mind.

  1. 4.

    Overarching Theme: Striving to Do No Harm and Yet Respect Patient Autonomy

The ongoing push-pull between competing ethical principles was the dominant theme; specifically, striving to balance parallel responsibilities to maintain non-maleficence from more extensive surgery while also respecting patient autonomy to undergo bilateral mastectomy. In particular, the participants were challenged by having to reconcile that CPM and breast reconstruction involves removing healthy tissue and introduces surgical complexity that may cause long-term morbidity but may also alleviate anxiety, create better symmetry, and improve self-esteem for select patients (Table 5).

Table 5 Overarching theme and representative quotes
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Discussion

This research was novel in providing additional modern insight into the CPM phenomenon and in being the first study to qualitatively examine plastic surgeons’ perspectives of the clinical encounter with women who have ESBC. Using the conceptual lens of biomedical ethics,20 four themes were developed: maintaining non-maleficence, supporting patient autonomy, delivering (un)equal healthcare, and providing care to enhance well-being.

Overall, Ontario plastic surgeons felt the push-pull between providing care that patients request, yet also adhering to guideline recommendations, and avoiding introducing additional risks to patients from more extensive surgery. This is supported by previous research showing that nearly 60% of surveyed general surgeons reported discomfort performing CPM for non–high-risk patients.30 Similarly, Covelli et al.12 found that CPM was frequently discouraged by general surgeons during their consultations with average-risk patients who have breast cancer due concerns about potential treatment delays and a lack of evidence demonstrating oncologic benefits.

The paradigm of the patient–physician relationship has transformed over the years toward increasing acceptance of the patient’s voice in treatment decision-making, which has created unique challenges in terms of providing evidence-based care. This is further complicated in that patients and physicians do not always value similar outcomes. For instance, for many conditions, physicians frequently overemphasize clinical outcomes and underrate the significance patients place on quality of life.31 Accordingly, it is important to recognize that what provides the greatest benefit from a medical standpoint may not be best from a patient perspective,32 thus highlighting the need for physicians to elicit preferences and support patient autonomy while making treatment decisions.

Respecting autonomy is crucial, but it is not realized by simply granting every patient request.32 Despite a desire to be patient-centered, a persistent concern among surgeons is that women with ESBC frequently make fear-based decisions due to overestimations of the likelihood of a recurrence or of developing cancer in the contralateral breast, which motivates them to pursue aggressive treatment.11,33,34 Therefore, autonomy is best supported via shared decision-making (SDM), in which physicians and patients actively communicate in a two-way exchange of information and preferences, resulting in a treatment that both parties find to be agreeable.33,35

In the breast cancer setting, SDM is especially suitable as patients encounter treatments with clinical equipoise and must carefully consider the inherent benefits and risks of each option.36 Recently, the American Society of Breast Surgeons recommended that physicians facilitate SDM by incorporating discussions of CPM into their consultations, engaging patients throughout the clinical encounter and ensuring that the final treatment plan aligns with their preferences and goals. 27 Similarly, a Canadian consensus statement concluded that CPM may be performed in patients with ESBC if both patients and surgeons deem it to be suitable after a detailed discussion of the rationale, costs, and benefits.28

Study Limitations and Future Directions

Although the participants varied in terms of demographic factors, sampling was limited to cancer centers in Ontario. The opinions expressed in this report may not be reflective of those in other settings, as cultural attitudes toward CPM and breast reconstruction may differ across geographic regions.37 Furthermore, this study included perspectives of plastic surgeons working within a universal healthcare system, which may present unique challenges compared with healthcare systems in the United States and beyond. Future research would benefit from interviews with a broader range of surgeons from diverse decision-making environments and payer systems.

Conclusions

In this evolving decision-making climate, plastic surgeons are mindful that patients may value outcomes, such as quality of life, above other clinical factors and are willing to accept additional risks to achieve them. Given that the ongoing controversy surrounding CPM is predominantly about avoiding harm, it is important to maintain a critical perspective on how harm is defined (surgical vs psychological harm) and to consider how some viewpoints may be privileged over others in the decision-making process. As CPM is a permanent choice that may lead to negative emotional and physical sequelae, it is also important that patients acquire a full understanding of the costs and benefits in order to properly evaluate these against their desired outcomes.

In the context of rising CPM rates, plastic surgeons accept and continuously grapple with the ethical responsibility to effectively communicate comprehensive medical information and counsel patients in a manner that allows them to make informed choices, reduces their anxiety, and also respects their preferences and values. Shared decision-making will help to reveal the motivations behind each individual’s treatment decisions, thus allowing physicians to appropriately weigh patient requests with current medical evidence.