Who’s Deciding? A Study of Patient-Surgeon Discussions About Contralateral Prophylactic Mastectomy

Background Despite rising rates of contralateral prophylactic mastectomy (CPM), little is known about how surgeons and patients communicate about the procedure. This study is among the first to use real-time audio recordings of CPM discussions, link conversations to treatment choice, and include multiple institutions. We assessed surgeon-patient discussions, focusing on how often CPM was addressed, who initiated it, and how decisions were made. Methods We recruited surgeons and patients from three academic centers and audio-recorded the first surgical consultation for patients with (1) early-stage unilateral breast cancer or ductal carcinoma in situ and (2) no strong family history or BRCA mutation. Transcripts were analyzed using an inductive, qualitative approach to generate themes and detect patterns. Results Twenty-seven patients and eight surgeons participated. In 14 cases, neither patient nor surgeon mentioned CPM. In the remaining 13, surgeons initiated the topic in 10, typically while introducing surgical options. Of the four patients who received CPM, each had a strong initial preference for CPM and was undeterred by the surgeon’s cautionary statements against it. When patients lacked strong preferences for CPM, they generally followed surgeon recommendations to forego CPM or to delay the decision until tests (eg, genetics and MRI) were complete. Discussion Surgeons, not patients, most commonly initiated CPM discussions. Initial patient preference strongly influenced surgical decisions. Surgeon recommendations to wait for additional information shaped decision making only when patients were initially undecided. Future research should explore how patients form preferences prior to consultation and how best to address them during clinical conversations.