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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 2  |  Page : 915-919

Iranian women's attitude toward prophylactic mastectomy for breast cancer


1 Cancer Genetics Group, Breast Cancer Research Center, ACECR; Tasnim Biotechnology Research Center, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
2 Cancer Genetics Group, Breast Cancer Research Center, ACECR, Tehran, Iran

Date of Web Publication25-Jul-2016

Correspondence Address:
Masoud Habibi
Vanak Square, South Gandhi, No. 146, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.171363

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 > Abstract 


Aim: Breast cancer is the most common cancer among women worldwide. Science has already proved that some breast cancer genes are inherited from parents. It is generally believed that the probability of cancer diagnosis in carriers of those genes is considerably higher than the normal population. It is in the same direction that modern medicine has introduced prophylactic mastectomy – one of the key preventive methods which is the focus of the present research. Nevertheless, whether women that have been diagnosed with breast cancer would take this approach depends on their local culture and their set of beliefs. In this regard, the present research was meant to evaluate the acceptability rate of prophylactic mastectomy among women in Iran after they are informed of the positive genetic test results.
Methods: Six hundred and five healthy women, who had no history of breast cancer, were selected by nonprobability sampling method. A predesigned questionnaire was filled out by the interviewer.
Results: Results showed that about 15% of respondents were willing to pick the prophylactic mastectomy in case they are identified as carriers of breast cancer genes. Twenty-two percent of participants with positive family history was agreed with prophylactic mastectomy while in the negative family history group it was about 14%.
Conclusion: Preventive mastectomy has a higher rate of acceptability among women who have had a family history of breast cancer. Therefore, it may be concluded that raising public awareness about the advantages of prophylactic mastectomy could help better address breast cancer in Iran.

Keywords: Attitude, breast cancer, Iranian women, prophylactic mastectomy


How to cite this article:
Majidzadeh-A K, Farahmand L, Zare AA, Esmaeili R, Salehi M, Habibi M. Iranian women's attitude toward prophylactic mastectomy for breast cancer. J Can Res Ther 2016;12:915-9

How to cite this URL:
Majidzadeh-A K, Farahmand L, Zare AA, Esmaeili R, Salehi M, Habibi M. Iranian women's attitude toward prophylactic mastectomy for breast cancer. J Can Res Ther [serial online] 2016 [cited 2019 Jun 20];12:915-9. Available from: http://www.cancerjournal.net/text.asp?2016/12/2/915/171363




 > Introduction Top


The association between increased risk of breast cancer and a previous positive family history for the disease was first described by Paul Broca in 1850 from his family.[1] After several years of study and research, it was in 1994 and 1995 that the scientists finally realized that a large proportion of such familial inheritance of breast cancer is linked to mutations in two tumor suppressor genes called BRCA1 and BRCA2, which are highly penetrant and follow an autosomal dominant pattern of inheritance.[2],[3] It has been established that the possibility of breast cancer in females with either one of these two genes is 50–85% and consequently 150 times higher than healthy females.[4] These two susceptibility genes can be identified in healthy people belonging to the families with the possibility of breast cancer inheritance using molecular methods. At present, these methods are quite common in many medical centers around the globe. The early detection and prevention methods are as follows:[5]

  • Intensive surveillance for early detection using typical methods, including breast examination, self-exam, ultrasound, mammography, or magnetic resonance imaging: Although early detection facilitates the treatment process, it does not guarantee full recovery considering the nature of malignant cancers, especially hereditary ones
  • Bilateral prophylactic mastectomy
  • Bilateral prophylactic oophorectomy
  • Chemoprevention.


It is obvious that each of the methods would be selected based on the situation of the cases through the genetic counseling process.

In the field of chemoprevention, there have been several clinical trials to determine whether tamoxifen is efficient in breast cancer prevention. In a trial by The American National Surgical Adjuvant Breast and Bowel P-1, 13,000 healthy women were studied. In similar trials by Royal Marsden Hospital and European School of Oncology/Italian Group, 2500 and 5000 healthy women were studied, respectively.[5]

An efficient measure that can help the carriers of the susceptibility genes is a bilateral prophylactic mastectomy. However, it should be noted that mastectomy can have psychological and moral consequences if performed on women not afflicted with any serious illness. Is it right to recommend mastectomy to a person who is merely a carrier of a susceptibility gene with no symptom of cancer? If the answer is negative, then the necessity of diagnostic, genetic methods decreases to a considerable extent. However, if the answer is positive, then such methods should be expanded and developed. Currently, reconstructive surgery makes it possible to reconstruct a breast after mastectomy. This can increase the acceptability of mastectomy among carrier females. However, most studies ignore this fact and patients are not informed of the possibility of breast reconstruction after mastectomy.

Since on the one hand, this is a progressive topic in medical centers, and on the other, cultural, religious, and social norms and beliefs can greatly affect the acceptability of prophylactic mastectomy, the present study was conducted to collect the opinion of Iranian women about prophylactic mastectomy after genetic testing.


 > Methods Top


Six hundred and five healthy women, who had no history of breast cancer, were selected by nonprobability sampling method. Educational brochures were distributed among the women. brochures contain data about the nature of breast cancer and its etiology, its genetic aspects and the role of genetic testing as a screening method for finding carriers and also a diagnostic method for inherited subtype and possible preventive measures. The allocated time for studying the brochure was 10–15 min. During the time of studying, women were allowed to ask any question from the staff, who were specially trained for the purpose. Then, a predesigned questionnaire was filled out by the interviewer. In the cases of limited literacy, the clinic staff would give the necessary information to the individual during an interview and read out the questionnaire to her and fill it as she answered. The following questions were asked from participants about their opinion on prophylactic mastectomy:



  • If genetic testing establishes the existence of a breast cancer susceptibility gene in a woman, which method would you recommend to her to prevent breast cancer?

    • Prophylactic mastectomy and removing both breasts
    • Using medicine
    • Regular examining and mammography
    • None of the methods are necessary.
    • Imagine that one or more of your relatives have breast cancer. Are you willing to be informed of the possibility of breast cancer in other members of your family?
    • Imagine that genetic tests are necessary to examine the danger of breast cancer in the members of your family; do you agree with such tests?
    • If genetic tests establish the existence of a breast cancer gene in a woman, there is a possibility that the other members of her family might be carriers as well; do you agree with the idea that the carrier should inform the other members of her family of the test results?
After the questionnaires had been filled out, SPSS software, (v.18) was used to analyze the collected data. First, all variables were descriptively analyzed. Then, the logistic regression analysis was used to find the relation between the important factors, including “preferred method for preventing breast cancer in the case of a positive result in genetic tests” and other factors such as age, education, and “breast cancer family history.”

Moral observations

All women were briefed on the study, asked whether they liked to help with the research and signed a written consent. In order to prevent anxiety among participating, they were selected only after the screening when it was established that they did not have breast cancer. They were informed that the questions had been designed for research purpose only and were not related to their current status at all. Furthermore, the sampling was conducted on reception and before checking for any legal suing. Limitations of the study included discontent of some women to join the research.


 > Results Top


Six hundred and five healthy cases were studied in the current research based on variables including age, marital status, family history, death cases resulting from breast cancer, and the number of female members in the first and second degree relatives. [Table 1] indicates the relative frequency distribution of the cases under study based on the mentioned variables.
Table 1: Relative frequency distribution of attitude of the study cases toward prophylactic mastectomy

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The cases were between 17 and 79 years old, with the average of 37.87, the standard deviation of 9.8, and standard error mean of 0.4. In 7 cases (9.8%), history of breast cancer among the first-degree relatives was reported, out of which 3.5% sisters and 6.3% mothers were involved. In 14.1% of the cases, at least one breast cancer was reported in the second-degree relatives such as grandmother, aunt, or granddaughter. In 89.8% of cases, no breast cancer was reported in the second-degree relatives. In 80 cases (13.2%), at least one breast cancer was reported in the first or second-degree relatives. In 7 cases (1.2%), breast cancer was reported in both the first and second-degree relatives.

Results illustrate that 15.4% of the cases prefer prophylactic mastectomy, and 84.6% recommend other methods.

[Table 2] indicates the relative frequency distribution of the cases based on variables including age, marital status, family history, death cases resulting from breast cancer, and the number of female members in the first and second degree relatives. The method under study was prophylactic mastectomy. The age factor was inserted in the model quantitatively. Three modes of “Under high school diploma,” “High school diploma,” and “Academic education” were specified for the education factor with the “Under high school diploma” state as the base. Three modes of “Single,” “Married,” and “Divorced/Widowed” were specified for the marital status factor. The breast cancer history in the first- or second-degree relatives was specified by positive or negative modes.
Table 2: The relative frequency distribution of the study cases based on variables including age, marital status, family history, death cases resulting from breast cancer, and the number of female members in the first and second degree relatives

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The present study has used Chi-square and Fisher Exact test to study the relations among parameters. Based on the results in [Table 2], none of the parameters had any meaningful relation at the level of 5% with the attitudes of individuals toward mastectomy. The researchers then studied the relationship between the attitudes of individuals toward mastectomy with the parameters of this research in groups with a positive history of breast cancer. The results show that there is only a meaningful relationship with the parameter on the number of female children (P = 0.03, χ2 = 6.6). The attitudes of individuals toward mastectomy proved to be positive among those with the upper number of female children. Almost 80% of individuals, who had a favorable attitude, had a positive family history of cancer. The favorable and disapproving attitudes of participants toward mastectomy have been provided in Table. A look at the table shows that most of the individuals with a favorable attitude toward preventive mastectomy were aged 30–40, were married, and had a college degree.

[Table 2] shows the univariate Pearson inter-correlations in the total sample between the dichotomized intention and the sociodemographic.

[Table 3] indicates the cases' awareness of the danger of breast cancer incidence in other members of their family. Based on the results, 94.5% agreed with been informed of the danger in cases with breast cancer history in their family. Furthermore, 95.4% of participants with positive family history were agreed.
Table 3: The relative frequency distribution of the attitude of cases under study toward being informed of the danger of breast cancer incidence in cases with breast cancer history in their family

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[Table 4] indicates the attitude of the cases under study toward genetic examining for determining the possibility of breast cancer incidence. Based on the results, about 94% of the cases agreed with genetic examining. In addition, about 92% of cases with positive family history were agreed.
Table 4: The relative frequency distribution of the attitude of cases under study toward genetic examining for determining the possibility of breast cancer incidence

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 > Discussion Top


The present study is the first one carried out on the Iranian women's viewpoint toward preventive mastectomy for breast cancer prevention based on genetic testing. The present study was carried out by 605 healthy women with no history of breast cancer. A direct relationship was established between women's reaction to mastectomy and history of number of daughters. However, there was no direct relationship between participates reaction to mastectomy and their age, marital status, their education, the history of breast cancer in their family, and history of death from breast cancer among relatives. Moreover, the majority of the participants in the study was in favor of being informed of breast cancer risks if there are cases of cancer in their family, carrying out genetic testing to determine risks to other family members and informing family members of the results, if the test results are positive.

The extent to which the mutation carrier women agree with the preventive mastectomy varies considerably in different cultures. It has been between 3%[6] in the US and 51%[7] in the Netherlands.

Another reason for the differences in agreeing with preventive mastectomy in different cultures might be doctors' faith in bilateral mastectomy in such cases. Few doctors in France recommend this surgery, even for the BRCA1 and BRCA2 mutation carriers.[8] In the US, doctors are more open toward this surgery with 29% of obstetricians and 50% of general surgeons recommending this surgery to the mutation carriers, as shown in a study.[9]

One of the studies in this regard has been carried out by Meiser et al. in 2000. They measured the willingness of 333 healthy women with high risks for hereditary breast cancer though to undergo preventive mastectomy. Only 19% of the participants considered mastectomy to be acceptable while 47% of them did not consider it to be acceptable, even if their genetic testing finds mutations in breast cancer genes.[10]

The same group carried out a similar study over 371 participants in Australia in 2003. Of the participants, 16% considered preventive mastectomy acceptable, 33% considered preventive ooforectomy acceptable, and 23% considered taking prevention drugs acceptable, if drugs are proven to be effective. Results of another multicenter study, which was conducted by Julian-Reynier et al. in France, Britain, and Canada, showed that mammography screening and the preventive medication had the highest acceptance with 87% and 58%, respectively. However, the preventive ooforectomy and mastectomy were acceptable to only 19% and 16% of the study participants.[11]

Another study about women's viewpoint toward the subject was carried out over 102 Singaporean women by See et al. in 2005. With regard to preventive surgery, 41.3% of the participants did not consider it, 13% considered it, and 45.7% did not consider the preventive surgery at the time study was carried out but said they may consider it in the future. With regard to prevent medication, 57% considered it while 26.9% did not.[12]

Results achieved in a similar study carried out by Julian-Reynier CMet al. in 2001 indicated that 20% considered breast preventive surgery acceptable with 43.8% refusing to undergo the preventive surgery. The answer of 31.7% of the participants was undetermined, and 3.4% chose other options. Acceptance of preventive oophorectomy was higher compared to preventive mastectomy with 54% of women accepting preventive oophorectomy.[12]

Welkenhuysen et al. conducted a study on students in an educational institution Brussels in 2001. Among study participants, 21% were certainly willing to undergo genetic testing, 45% said they would probably consider it, and 34% defiantly refused it.[13]

Another study was carried out by Metcalfe et al. in 2000 over 79 BRCA1 and BRCA2 mutation carriers. Fifty-two percent of these women were willing to undergo breast or ovarian cancer preventive surgeries. The willingness to preventive surgery was 80% among women aged under 50 and 45% among those aged above 50. Women with higher levels of education were more eager to undergo preventive surgery.[14]

In this study, most of the individuals who had a favorable attitude toward preventive mastectomy aged 30–40, were married, and had a college degree. Furthermore, the participants were divided into two groups: One with a positive family history and another with a negative history of breast cancer. Results show that the favorable attitude toward preventive mastectomy in the first group stood at about 22%, while it was about 14% in the second group. Further, there was a meaningful relation between choosing preventive mastectomy and the number of female children in positive family history. As for the need to go through genetic tests and having prior knowledge about the risks of the development of breast cancer among other family members of a patient, the favorable attitude in the first group (positive family history) was higher. It appears that these differences show the first group is more aware about breast cancer and its impacts – what has eventually made preventive mastectomy to be regarded favorably. Besides, another point made clear as the result of the present research was that married individuals or precipitates who have female children have a favorable attitude toward preventive mastectomy due to concerns over the future of the children and the general health of the family.

So, it is necessary to raise public awareness about the benefits of mastectomy in preventing the development of breast cancer. This, of course, needs to be carried out through the educational programs. What is specifically significant in this direction is the fact that reconstructive surgery can be a great help to encourage people to undergo mastectomy.

Studies conducted in this regard have led to various results, but from another aspect, preventive bilateral mastectomy is a matter of ethical issue rather than a medical decision. From this perspective, this surgery faces several challenges. First, this is not considered as a dangerous condition of a disease, and prevention does not lead to recovery. Furthermore, the surgery's benefits would make sense when considered statically and on the population scale. Second, a genetic factor, which is arguable, is the reason for this threat. Third, no organ in women is associated with their feeling of femininity, motherhood, maturity, and gender more than breasts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
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2.
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Bishop DT. BRCA1, BRCA2, BRCA3. A myriad of breast cancer genes. Eur J Cancer 1994;30A: 1738-9.  Back to cited text no. 3
    
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Calderon-Margalit R, Paltiel O. Prevention of breast cancer in women who carry BRCA1 or BRCA2 mutations: A critical review of the literature. Int J Cancer 2004;112:357-64.  Back to cited text no. 5
    
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Lerman C, Hughes C, Croyle RT, Main D, Durham C, Snyder C, et al. Prophylactic surgery decisions and surveillance practices one year following BRCA1/2 testing. Prev Med 2000;31:75-80.  Back to cited text no. 6
    
7.
Meijers-Heijboer EJ, Verhoog LC, Brekelmans CT, Seynaeve C, Tilanus-Linthorst MM, Wagner A, et al. Presymptomatic DNA testing and prophylactic surgery in families with a BRCA1 or BRCA2 mutation. Lancet 2000;355:2015-20.  Back to cited text no. 7
    
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Julian-Reynier C, Eisinger F, Moatti JP, Sobol H. Physicians' attitudes towards mammography and prophylactic surgery for hereditary breast/ovarian cancer risk and subsequently published guidelines. Eur J Hum Genet 2000;8:204-8.  Back to cited text no. 8
    
9.
Geller G, Bernhardt BA, Doksum T, Helzlsouer KJ, Wilcox P, Holtzman NA. Decision-making about breast cancer susceptibility testing: How similar are the attitudes of physicians, nurse practitioners, and at-risk women? J Clin Oncol 1998;16:2868-76.  Back to cited text no. 9
    
10.
Meiser B, Butow P, Friedlander M, Schnieden V, Gattas M, Kirk J, et al. Intention to undergo prophylactic bilateral mastectomy in women at increased risk of developing hereditary breast cancer. J Clin Oncol 2000;18:2250-7.  Back to cited text no. 10
    
11.
Julian-Reynier CM, Bouchard LJ, Evans DG, Eisinger FA, Foulkes WD, Kerr B, et al. Women's attitudes toward preventive strategies for hereditary breast or ovarian carcinoma differ from one country to another: Differences among English, French, and Canadian women. Cancer 2001;92:959-68.  Back to cited text no. 11
    
12.
See HT, Cheung YB, Yong F, Khoo KS, Ang P. Acceptance of prophylactic surgery and chemoprevention of cancer in Singapore – A survey. Ann Acad Med Singapore 2005;34:238-42.  Back to cited text no. 12
    
13.
Welkenhuysen M, Evers-Kiebooms G, Decruyenaere M, Claes E, Denayer L. A community based study on intentions regarding predictive testing for hereditary breast cancer. J Med Genet 2001;38:540-7.  Back to cited text no. 13
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14.
Metcalfe KA, Liede A, Hoodfar E, Scott A, Foulkes WD, Narod SA. An evaluation of needs of female BRCA1 and BRCA2 carriers undergoing genetic counselling. J Med Genet 2000;37:866-74.  Back to cited text no. 14
    



 
 
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