Choosing Mastectomy: A Qualitative Exploration of the Increasing Mastectomy Rates in Women with Early-stage Breast Cancer

Context: Rates of Unilateral (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Numerous factors for this rise have been suggested including the surgeon's preference, the patient's choice and the external environment. Objectives: A grounded theory study explored women's decision-making processes in their treatment for ESBC, and elucidated the role of the surgeon and the practice environment in the increasing rates. The Health-Belief Model was applied, discerning those factors influential in surgical decision-making shaping women's choice for UM+/-CPM. Design: Semi-structured interviews were conducted with patients to understand their experiences and decision-making which resulted in undergoing UM+/-CPM. Similarly, semi-structured interviews were conducted with general surgeons exploring their treatment approaches to ESBC. Theoretical sampling identified suitable candidates. Data were collected until saturation was reached. Constant comparative analysis identified key concepts. Results: 29 patients and 45 surgeons completed interviews. The `overwhelming threat' of breast cancer `was the dominant theme. Despite surgeons describing the high survivability of ESBC, patients misperceived the threat of death from their cancer, and strived to eliminate this threat by choosing UM+/-CPM. Surgeons described breast-conserving therapy (BCT) and UM as equivalent treatment options for ESBC, and frequently recommended BCT. Despite this, women requested UM+/-CPM. CPM was discouraged, as surgeons described no survival advantage and increased operative risks. Experiential knowledge was the most influential factor in patients' decision-making. Previous negative experiences of family and friends with breast cancer, translated into an overestimated risk of recurrence, contralateral cancer, metastasis and subsequent death. Patients' perceived the risks and severity of ESBC to be great, and believed that by choosing UM+/-CPM they would eliminate the threat of breast cancer. Most women did not perceive any risks of undergoing UM+/-CPM, yet many experienced concerns with disturbed skin sensation, cosmesis and body image. Conclusion: Previous cancer experiences and experiential knowledge are extremely influential in women undergoing UM+/-CPM. Women overestimated their risk and misperceived the benefit of UM+/-CPM as they thought it would substantially improve their cancer outcomes. As undergoing UM+/-CPM is not without risks improved discussion of patient sources of information and fears around survival may benefit surgical consultations, facilitating informed decision-making.Ph.D.2016-12-18 00:00:0