Increasing mastectomy rates-the effect of environmental factors on the choice for mastectomy: a comparative analysis between Canada and the United States.

PURPOSE: Unilateral mastectomy (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Numerous etiological factors for this rise have been suggested, including increasing use of magnetic resonance imaging (MRI) and reconstruction, surgeon's preference, and patient's choice. We conducted a qualitative study to explore what role the surgeon and their practice environment play in the increasing rates.
METHODS: Semi-structured interviews were conducted with general surgeons to explore their current approach to treating ESBC and their experience with women requesting mastectomy. Purposive sampling identified surgeons across Ontario, Canada, and the United States (US). Constant comparative analysis identified key concepts.
RESULTS: Data saturation was achieved after 45 interviews. 'The effect of external factors on rising mastectomy rates' was the dominant theme. All surgeons described increasing mastectomy rates over the last 5 years, and all surgeons discussed breast-conserving therapy (BCT) and UM as equivalent options. However, US surgeons discussed reconstruction early in the consultation process, reflecting legislative requirements. In contrast, Ontario surgeons discussed reconstruction only when a patient was considering mastectomy. Ontario surgeons often recommended BCT, whereas US surgeons rarely made a direct recommendation regarding the extent of surgery. Neither US nor Canadian surgeons recommended the use of UM + CPM in average-risk ESBC, and all surgeons described women initiating this request. MRI use and access to immediate breast reconstruction also impacted the choice for mastectomy.
CONCLUSIONS: Use of MRI, access to reconstruction, and legislative requirements regarding information disclosure, appeared to influence the surgical consultation process and the patient's request for CPM.