Prophylactic mastectomy? How to counsel patients
When a woman asks if she is a candidate for preventive breast removal, Dianne D. Chapman, RN, MS, OCN, asks where she got her information. "It might be erroneous. We straighten it out, and she may not think about it again," says the coordinator and genetic nurse counselor at Chicago’s Comprehensive Breast Center at Rush-Presbyterian-St. Luke’s Medical Center.
For women who have a familial breast cancer history, Chapman and her colleagues do a "pedigree" consisting of:
o Breast cancer incidence across three generations, including the patient’s sisters, mother, mother’s and father’s sisters, and grandmothers on both sides.
o Ages when breast cancer occurred. "If they got cancer in their sixties or seventies, it usually levels her risk to that of the general population," Chapman explains.
o Familial incidence of ovarian cancer. "That’s a red flag," she says, "because the incidence is much less than breast cancer."
Depending on the history, Chapman determines the risk. "Today the lifetime breast cancer risk is 12% in the general population. We see patients with a 20 to 85% lifetime risk."
At a 20% risk, Chapman and colleagues would not recommend preventive mastectomy. "Where it becomes hazy is in the 50% category," she observes. Fear is a factor in the decision. "If anxiety jeopardizes her emotional well-being, surgery can change her life because it reduces the biological risk by 90%," Chapman explains, adding, "We never encourage someone to have the surgery, however."
Instead, she encourages the woman to invite family in for discussion, especially the significant other. For disease-free clients, "We tell them to go away and spend a lot of time thinking about this so we can make sure it’s not a knee-jerk decision.
"We slow them down on purpose," Chapman says. "We want them to be happy with this surgery 40 to 50 years down the line."
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