Contralateral Prophylactic Mastectomy
Rates have doubled in recent years, but is it necessary for prevention?
omen with unilateral breast cancer
W have a high risk of developing
cancer in the unaffected breast.
These patients have many treat-
ment options; however, the rate of
contralateral prophylactic mastectomy (removal of
the unaffected breast) have been steadily rising. A
study conducted by Tuttle and colleagues in the
Journal of Clinical Oncology found that the rate
of contralateral prophylactic mastectomy doubled
from 1998 to 2003. This increasing trend contin-
ued to the end of the study period, without any
plateau. The authors also noted that patients
appeared to be increasingly choosing either mini-
mal surgical procedures or a bilateral mastectomy,
instead of a unilateral mastectomy.
The study didn’t address the reasons why increas-
ing numbers of women are choosing this treatment,
but Marisa Weiss, MD, founder and president of
www.breastcancer.org, explains that the reasons
are complex and highly individual. “Both medical
circumstances and emotional issues may be mak-
ing it a more common option,” she says.
Women opting for contralateral prophylactic
mastectomy may have more extensive disease, vas-
cular and lymphatic invasion, or more than one
cancer in the breast, Weiss explains. “There is more
public awareness of the genetics of breast cancer,
and a lot of young women are getting genetic coun-
seling. The whole process may reveal a strong fam-
ily or genetic history, and patients are given real
information that they should be concerned about.”
Weiss also points out that breast cancer has
become very visible over the past 30 years, and
while women have become more aware of the dis-
ease, they are also increasingly worried. “When
women are diagnosed with breast cancer, many
want to do everything possible to prevent it from
happening a second time.”
Tuttle and colleagues also found that the rate of
contralateral prophylactic mastectomy increased
from 1.8% of all surgeries in 1998 to 4.5% in
2003. In addition, the percentage of contralateral
prophylactic mastectomy accounted for 11% of all
mastectomies in 2003, up from 4.2% in 1998. The
patients most likely to choose contralateral prophy-
lactic mastectomy in this study were non-Hispanic
26 AJN ▼ February 2008 ▼ Vol. 108, No. 2
whites, women with lobular breast cancers, and
those with a previous cancer diagnosis. A younger
age was also associated with a significantly higher
rate of contralateral prophylactic mastectomy.
Among those with surgically treated breast cancer,
6.7% of women ages 18 to 39 underwent con-
tralateral prophylactic mastectomy, as opposed to
1.3% of women ages 70 to 79.
“Many of these young women are physically
active, they see themselves as healthy and living a
healthful lifestyle and are shocked by a breast can-
cer diagnosis,” says Weiss.
However, Tuttle and colleagues point out that
contralateral prophylactic mastectomy is “aggressive
and irreversible; it is also not necessary for prevent-
ing contralateral breast cancer in most patients.”
The majority of participants in their study had three
surgical options: breast conserving surgery, unilat-
eral mastectomy, or bilateral mastectomy. Among
152,755 patients with breast cancer, 59,460 under-
went unilateral mastectomy while 4,969 opted for
contralateral prophylactic mastectomy, even though
a single mastectomy was also an appropriate option.
Survival Benefit and Satisfaction. Tuttle and
colleagues acknowledge that other studies have
shown that contralateral prophylactic mastectomy
can decrease the risk of contralateral breast cancer,
but a clear survival benefit has not been determined.
“But there doesn’t necessarily need to be a
straightforward survival advantage for this to be a
viable option for breast cancer patients,” says
Marybeth Singer, MS, APRN,BC, AOCN, ACHPN,
an NP from the Gillette Center for Breast Oncology
in Boston. “We need to look at the quality of sur-
vival. For many women, the rigors of undergoing
routine follow-up and waiting for that ‘all clear
sign’ are extremely stressful.”
This was the case for Helen, a 59-year-old NP
who works in a large New York City hospital and
had a bilateral mastectomy. Helen says, “I couldn’t
take the stress of frequent follow-ups, mammo-
grams, and worrying about more surgery. It’s the
best decision I ever made. I was back to work in
three weeks.”
Singer points out that cancer treatment is highly
individualized. “Even if the approach [to treat-
ment] is not one that you as a nurse would make
http://www.nursingcenter.com
 Courtesy of Jamie DiVenere
Dianna Matherly (above) was diagnosed with breast cancer in 1985, at the age of 21, and underwent a lumpectomy. Ten years later
the cancer reappeared, and she decided to have both breasts removed. But when she told her clinicians she didn’t want breast
reconstruction, she was faced with incredulity and resistance. Matherly and photographer Jamie DiVenere chronicled her journey,
and the result was 21/31 Dianna, a show of photographs and video pieces that toured galleries and clinical settings around the
country. Today, Matherly is a successful artist in Massachusetts and has a son of four and a half. You can see more of her work at
www.diannamatherly.com.

for yourself,” she says, “You need to support the
patient and help her get the facts straight.
“Nurses are often the first-line people that
patients see, so our role is extremely important. But
nurses need to be aware of the literature and work
with patients to manage their anxiety, lower their
risk, and improve lifestyle factors.”
The majority of women who undergo contralat-
eral prophylactic mastectomy tend to be satisfied
with that decision. Geiger and colleagues, as pub-
lished in the Journal of Clinical Oncology in March
2006, surveyed 519 women who underwent con-
tralateral prophylactic mastectomy and found that
86.5% were satisfied with their decision. More than
three-quarters reported a high level of contentment
regarding quality of life, and psychosocial outcomes
were generally similar to those in breast cancer sur-
vivors who had not undergone the procedure.
“Being satisfied doesn’t mean that everything is
perfect,” says Geiger. “But most women really
believe it was a good decision for them.”
However, Geiger also points out that their data
showed that women who chose contralateral pro-
phylactic mastectomy were not at a particularly
higher risk for recurrence. “Their risk was not
greater as compared with women who didn’t have
it done,” she says. “They may have just had more
anxiety about breast cancer.”
Women have also reported a better cosmetic out-
come when a bilateral mastectomy is performed.
They are likely to have better symmetry; breast
reconstruction may be more difficult when per-
formed on only one side. “In focus groups, women
have reported that it [reconstruction] was one of the
reasons [for prophylactic contralateral mastectomy],
although not the predominant reason,” says Geiger.
“Clearly, many factors go into making this decision.”
Decision Making Process. Tuttle and colleagues
reported on a review of the National Prophylactic
Mastectomy Registry that found the most common
reason patients selected prophylactic contralateral
mastectomy was physician advice. However, a 2005
survey by Nekhlyudov and colleagues in the Journal
of the National Cancer Institute Monographs
showed that 45% of respondents (N = 431) made
the decision to have contralateral prophylactic
mastectomy on their own. Another 37% reported
that they considered the opinion of their physician,
while only 3% reported that the physician “pri-
marily made the decision.”
Geiger suspects that the rates of contralateral
mastectomy may continue to rise, especially if
magnetic resonance imaging (MRI) of the breast
increases in popularity. “An MRI scan is more sen-
sitive than a mammogram and more likely to pick
up small irregularities in the unaffected breast. The
American Cancer Society is looking at expanding
its guidelines for breast MRI, and if that comes to
pass, we are likely to see this trend continue.”
—Roxanne Nelson, BSN, RN ▼

ajn@wolterskluwer.com AJN ▼ February 2008 ▼ Vol. 108, No. 2 27