Reflections on the Psychology of Prophylactic Mastectomy

In an earlier blog post,  Psychology and Prophylactic Mastectomy, I summarized an op ed piece written by Peggy Orenstein titled "The Wrong Approach to Breast Cancer" that appeared on Sunday, July 26th, 2014 in the New York Times.  In her article, Ms. Orenstein offered some possible psychological motivations for why women choose to have a healthy breast removed after being diagnosed with breast cancer in the other breast, despite the fact that survival is not increased by doing so.  I would like to offer additional thoughts on psychological motivation.

Loss Of Control

Breast cancer patients like other cancer patients where extensive treatment is required, usually undergo the experience of a profound loss of control over their lives. Asking the question, “Why me?" is one way that cancer patients attempt to regain some control or at least some understanding about possible causation.  Some spend a lot of mental energy reviewing their lives and wondering what may have triggered or contributed to the development of the cancer.

Humans want and need to feel that they have a certain amount of control over their lives in order to function in calm, organized and productive ways. We want to believe that if we eat properly, exercise often, avoid cigarettes, get enough sleep, maintain the correct weight, and so on, then we will be able to avoid serious physical illnesses, at least until old age.  Mass media plays to these hopes. Our newspapers, health newsletters, and journals are replete with reports of studies in which associations have been found between a myriad of foods, vitamins, and behaviors and a lower or higher incidence of some type of cancer, continually reinforcing the idea that if we can just figure out what to do and then do it, we will be able to greatly reduce our chances of getting cancer. People are encouraged to imagine that they have more control over what happens to their bodies then they, in fact, have. When a cancer diagnosis is made, it is often a shocking reminder of how little control we actually do have. In addition to feeling shocked or frightened, a patient may also feel a sense of shame over having failed to do what was necessary to prevent the cancer.  Making the decision to have a healthy breast removed may offer a chance to regain some sense of being in control, and may also serve to diminish any guilt or shame over not having done the "right" things to prevent the cancer.

Religious Contributions

In some religions, such as Roman Catholicism, sex is viewed as primarily for procreation, and for the pleasure of married men.  Roman Catholic women are encouraged to engage in sexual relations only to have children and to please their spouses. Women who engage in sex for their own pleasure, or who use some form of birth control, are induced to experience varying degrees of conscious or unconscious guilt or shame. Sexuality may be experienced as a burden, something that has to be managed and dealt with, something that can lead to sinful behavior and eternal damnation. Breast cancer may be consciously or unconsciously viewed as a punishment, and giving up a breast, as a way to pay for one's sins, thereby restoring a sense of virtue as well as the possibility of a blissful afterlife in heaven with God.

Other psychological issues

Some women are conflicted about their sexuality or sexual attractiveness because they grew up in families in which their physical beauty or sexuality was the cause of jealousy, anxiety or sexual abuse.   In these situations, sacrificing a healthy breast may serve to expiate guilt or shame and the patient may actually experience relief when the breast is gone.

Prophylactic mastectomy has not been shown to affect survival in those who are not at increased genetic risk for breast cancer.  One can have still have a cancer recurrence in the tissue that's left or in some other part of the body.

Psychology and Proplylactic Mastectomy

On Sunday, July 26th, 2014, the New York Times printed an opinion piece written by Peggy Orenstein titled "The Wrong Approach to Breast Cancer" in which Ms. Orenstein relays the results of a study published in 2009 in The Journal of Clinical Oncology, showing that the rates of mastectomy with contralateral proplylactic mastectomy (removal of the unaffected breast) jumped dramatically for those with very early stage breast cancer between 1998 and 2005 (Tuttle et al, 2009).  Most of these women did not have an increased genetic risk for the disease. Ms Orenstein points out that this occurred even though this surgical procedure has virtually no survival benefit, i.e. women who choose to have this, are apparently not living longer according to a recent study that appeared in the Journal of the National Cancer Institute.  In one study, young women chose to have this done even though the majority knew that this procedure would not prolong life.  They even often cited enhanced survival as the reason.  In addition, there are often complications and side effects associated with contralateral proplylactic mastectomy (CPM) and breast reconstruction such as infections, ruptured implants and lack of sensation in the reconstructed breast.

Why are women apparently so willing to give up a healthy breast even when they are informed that it will not increase their survival?  Ms. Orenstein cites several possible psychological  motivations such as the desire to flee from the diagnosis and put the whole thing behind them as quickly as possible. She mentions the power of "anticipated regret" - i.e. women want to feel that they have done everything they can to prevent a recurrence, especially when they have young children. "Patients will go to extremes to restore peace of mind, even undergoing surgery, that paradoxically, won't change the medical basis for their fear."  She aptly points out that self-sacrifice has long defined what it means to be a good mother.