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Medical Meeting Reports

American College of Surgery Clinical Congress

October 10-15, 1999


PROPHYLACTIC MASTECTOMY ON DEMAND?
font=>By Paul Recchia, Ph.D.

A colloquium on ethical issues in genetics, moderated by Bernard Langer, MD, debated ethical implications of genetic testing on various diseased patients. One such case study involved a thirty year old women from an area endemic with breast cancer with a family history of breast cancer. The woman is convinced she is at high risk for breast cancer. The woman has read various popular literature and she has noticed recent studies touting success in early cancer treatment. Upon exam and mammography, her breasts have no disease and she shows no symptoms. The question the moderator raised was whether a surgeon should perform mastectomy and breast reconstruction on this woman. Dr. Langer noted that the colloquium was designed to encourage debate and that the opinions the surgeons expressed were not necessarily their own.

Provide Information, Attempt Discouragement, but Provide Mastectomy if She Persists

Ronald Rosenthal, MD, Orthopedic Surgeon at the Neuber Ethics College, said the surgeon may feel that he or she is being asked to treat a nondisease and that informing the patient should scare her from further demands for mastectomy and breast reconstruction. However, Dr. Rosenthal stated that frequent mammograms are by no means a guarantee of catching breast cancer in time. This information and the patient's readings can cause phobia of breast cancer. However, sending her to a psychiatrist is not the answer because her fear has some legitimacy. The patient watched two of her older relatives suffer and die from breast cancer. So, reasoned Dr. Rosenthal, her concerns are reasonable, she is at risk, her anxiety will only increase with age, and patient autonomy is important. While no procedure will reduce her risk to 0%, mastectomy is the closest procedure to reducing her risk to approaching 0%. Dr. Rosenthal said "Inform the patient about breast cancer, mastectomy and reconstruction risks, and if she still persists: 'Carpe Diem,' just do it!"

Assess Risk, Provide Information, Address Psychological Issues, but Refuse Mastectomy

Maurice Webb, MD, Mayo Clinic, said the patient should not have a mastectomy simply because she requests it. Basic details are required to make such a serious medical decision. Risk should be assessed by following the guidelines for prophylactic mastectomy: personal history, proliferative hyperplasia or severe dysplasia, and one primary relative and two secondary relatives with lobular or ductile breast cancer. This patient satisfies none of these conditions. Of her two aunts with breast cancer, only one had the disease premenopausally. Secondly, she should be properly informed about frequent exam and mammography, the complications of mastectomy and breast reconstruction (inability to breast feed, poor nipple sensation, sloughing of skin, uneven breast hardening, and failure of implants at 2% per year), the screening procedures for mutation risk, and her very low risk at age 30. Dr. Webb said, "If she persists, but her demands are not substantiated medically, refuse to perform mastectomy."

The panelists, composed of French Anderson, MD, Abdallah Daar, MD, Eric Jeungst, PhD, and Mark Sieger, MD, discussed the case of a demanding young patient showing no current symptoms of breast cancer. Out of this discussion, the panelists considered the possibility that this case may be low risk, instead of nondisease, but certainly not high risk, and that drawing the line for mastectomy should be decided by conferring with colleagues. They also suggested that genetic testing should be done not only on her but also on her extended family, and the patient should seek out a genetic counselor.

For professional correspondence, please contact Dr. Richard Langer at blanger@compuserve.com, Dr. Rosenthal at mrrosenth@aol.com, and Dr. Webb at webb.maurice@mayo.edu.

Ortho Biotech

Funded through an unrestricted educational grant by Ortho Biotech.



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