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PLASTIC RECONSTRUCTIVE AND REGENERATIVE SURGERY

Official journal of

Partner of

Breast

Vol. 4 - Issue 1-2 - April-August 2025

Mastectomy versus breast-conserving surgery: a systematic review of factors influencing patient choice against multidisciplinary team recommendations

Authors

Valerio Pasqualitto

Key words: breast cancer, mastectomy, breast-conserving surgery, patient choice, multidisciplinary team
DOI: 10.57604/PRRS-1366
Reconstruction
Publication Date: 2025-10-06

Summary

Background. Breast-conserving surgery (BCS) followed by radiotherapy e recommended approach for most early-stage breast cancers. However, a significant number of patients choose mastectomy even when multidisciplinary teams (MDTs) recommend BCS.
Understanding the factors influencing this decision is crucial for patient-centered care and optimal surgical outcomes.
Methods. A systematic review was conducted per PRISMA guidelines, searching PubMed, Scopus, PsycINFO, and CINAHL (2010 - September 2025) or studies on women with breast cancer offered BCS by MDTs but opting for mastectomy. Data on patient
demographics, reasons for choice, and decisional regret were extracted. Study quality was assessed using the Newcastle-Ottawa Scale and CASP checklist.
Results. Thirty-two studies were included. Between 6-21% of patients chose mastectomy against MDT advice, with higher rates among younger women and those with a family history. Key factors included fear of recurrence (reported by 60-80% of patients), body image concerns psychological closure, and radiotherapy burden. Satisfaction was high, but decisional regret was noted in 10–15% of cases, often linked to poor MDT communication.
Conclusions. Patient choice of mastectomy is driven by psychological informational, and social factors. Enhanced communication and decision aids can align choices with MDT recommendations, improving satisfaction and reducing regret.

INTRODUCTION

Breast-conserving surgery (BCS) with adjuvant radiotherapy is the standard of care for most women with early-stage breast cancer, offering survival rates equivalent to mastectomy and superior cosmetic and psychosocial outcomes 1-4. Despite multidisciplinary team (MDT) recommendations, a significant proportion of eligible patients opt for mastectomy. Recent meta-analyses 5 and registry data 6,7 indicate stable or increasing mastectomy rates, particularly among younger women and those with access to reconstructive surgery 8,9. The reasons for this divergence are complex, involving psychological, social, and informational factors 10-12. This systematic review aims to identify and analyze the factors influencing women with early-stage breast cancer to choose mastectomy over MDT-recommended BCS, with primary endpoints including patient-reported reasons for surgical choice, satisfaction, psychosocial outcomes, and decisional regret. Secondary endpoints include the prevalence of mastectomy choice against MDT advice and the impact of healthcare system costs on decision-making. Understanding these factors is vital for improving patient-centered care, reducing decisional regret, and ensuring informed, value-congruent choices.

METHODS

A systematic review was conducted according to PRISMA guidelines 13. PubMed, Scopus, PsycINFO, and CINAHL were searched for studies published in English from 2010 to September 25, 2025, including adult women with breast cancer offered BCS by an MDT but opting for mastectomy. Qualitative, quantitative, and mixed-methods studies with ≥ 30 patients were included. No additional studies meeting inclusion criteria were identified between May 2025 and September 2025. Data extraction focused on study characteristics, patient demographics, MDT recommendations, the proportion of patients choosing mastectomy against advice, and their reasons. Study quality was assessed using the Newcastle-Ottawa Scale 14 and CASP checklist 15. PROSPERO registration CRD420251056767.

ELIGIBILITY CRITERIA

Population: adult women with breast cancer offered and recommended BCS by an MDT.

Interventions/comparisons: patient choice of mastectomy versus BCS when MDT recommended BCS.

Outcomes: patient-reported reasons for surgery choice, satisfaction, psychosocial factors, and decisional regret.

Study types: qualitative, quantitative, and mixed-methods studies published in English in the last 15 years, with ≥ 30 patients.

STUDY SELECTION AND DATA EXTRACTION

Data were extracted using standardized forms, including study characteristics, patient demographics, MDT recommendations, number of patients choosing mastectomy against advice, and reasons for their choice. Study quality was appraised using the Newcastle-Ottawa Scale and CASP checklist. Thirty-two studies met inclusion criteria and were included in the final synthesis.

RESULTS

Of the 32 included studies, the proportion of patients choosing mastectomy against MDT recommendations ranged from 6% to 21% (median: 12.5%), with higher rates observed among younger women 11 (aged < 50 years, 15-21%) and those with a family history or genetic predisposition 16 (18-20%).

Key factors influencing the choice of mastectomy included:

Fear of recurrence: cited by 60-80% of patients across studies as the primary driver, despite equivalent oncologic outcomes for BCS and mastectomy 1-4.

Body image concerns: approximately 30-40% of patients preferred mastectomy with reconstruction due to concerns about asymmetry or radiation-induced changes after BCS 8,9,17.

Psychological closure: 25-35% of patients reported mastectomy provided peace of mind and reduced surveillance-related anxiety 18.

Radiotherapy burden: 20-30% of patients, particularly those living far from treatment centers, chose mastectomy to avoid radiotherapy’s logistical or side-effect challenges 5.

Information and communication issues: 15-25% of patients cited misunderstanding of recurrence risks or poor MDT communication as reasons for choosing mastectomy 12,19-22.

Social influences: 41% of patients in recent surveys reported peer stories or social media influencing their decision 20.

Decisional regret was reported in 10-15% of patients 23, often associated with inadequate information or lack of MDT support 21. Satisfaction rates were high (80-90%), particularly when shared decision-making tools were used 19,22. Cost influenced decisions in 18% of US patients 24,25 but only 3% in Italy and France 26,27.

IMPACT OF HEALTHCARE SYSTEM AND COSTS ON PATIENT DECISION-MAKING

In countries with universal healthcare (Italy 26,27 UK, Canada), patient choice is driven by medical, psychological, and social factors, with minimal cost influence. In Italy, financial barriers are negligible, allowing focus on recurrence anxiety and cosmetic outcomes 26,27. In the US, cost plays a substantial role, with 18% of patients citing financial concerns 24,25. Lower-income patients are less likely to access reconstruction, exacerbating disparities. Comparative studies show cost can tip decisions in borderline cases where insurance is incomplete 28,29.

COST CONSIDERATIONS AND INTERNATIONAL COMPARISONS

Recent studies have investigated the direct and indirect costs of mastectomy and BCS, as well as their impact on patient decision-making 24,25,30. In the United States, BCS is associated with lower initial surgical costs but higher cumulative costs due to adjuvant radiotherapy and surveillance 24. Mastectomy, particularly with reconstruction, incurs higher upfront costs but may reduce long-term surveillance expenses 24. In countries with universal healthcare systems like Italy, the UK, and Canada, out-of-pocket costs are minimal 27,36,37. Italian registry data show that less than 2% of patients cited financial concerns as a factor in their choice 35, compared to 10-15% in US cohorts 24. Recent studies report cost influencing surgical choice in 18% of US patients but only 3% in Italian and French patients [24-27] (Tabs. I-II, Fig. 1).

FACTORS INFLUENCING PATIENT CHOICE

Recurrence anxiety: fear of recurrence is the most commonly cited reason for choosing mastectomy 10-12. Despite similar long-term oncologic outcomes for BCS and mastectomy 1-4, patients often perceive mastectomy as more definitive. This anxiety is especially prevalent among younger women and those with a family history or genetic predisposition 11,16.

Body image and cosmetic issues: concerns about breast asymmetry, scarring, or radiation-induced changes after BCS lead some patients to prefer mastectomy with reconstruction, which is often perceived as providing a more satisfactory or symmetrical result 8,9,17. Recent advances in oncoplastic techniques have improved BCS outcomes, but not all patients are aware of these options 9.

Psychological well-being and peace of mind: many patients report that mastectomy offers psychological closure and reduces the need for ongoing surveillance, alleviating anxiety about recurrence 18,29.

Information processing and trust in health counselling: misunderstanding of recurrence risks, information overload, and lack of clarity in MDT communication contribute to the decision for mastectomy 12,19,21. Trust in the MDT and the quality of communication are crucial for concordance with recommendations 30. Recent studies emphasize the importance of visual aids and decision tools in improving understanding 22,31.

Social influences and anecdotal experience: the influence of social networks, including family, friends, support groups 20, and especially online communities and social media 20, has grown.

Perceived burden of adjuvant therapy: the anticipated inconvenience, side effects, or logistical challenges of radiotherapy after BCS lead some patients to prefer mastectomy to avoid additional treatments 5.

PREVALENCE AND TRENDS

The proportion of patients choosing mastectomy against MDT recommendations ranged from 6% to 21%, with higher rates among younger women and those with a family history 11,16. Recent registry data indicate that rates have not declined despite ongoing patient education efforts 6,7.

DECISIONAL REGRET AND SATISFACTION

Most patients report satisfaction with their surgical choice, but decisional regret is more common among those who felt inadequately informed or unsupported by their MDT 21,23. Shared decision-making, use of decision aids, and clear risk communication are associated with improved satisfaction and increased alignment with MDT recommendations (Tab. III) 22.

DISCUSSION

The decision-making process for breast cancer surgery is complex, driven by psychological, informational, and social factors. Fear of recurrence remains the dominant factor 10-12, cited by 60-80% of patients choosing mastectomy. Body image concerns, psychological closure, and radiotherapy burden also significantly influence decisions. The growing impact of online communities and social media 20 underscores the need for clinicians to counter misinformation with evidence-based guidance.

Similar studies, such as Katz et al. (2005) 32, found that patient involvement in decision-making was critical for satisfaction but often led to mastectomy due to risk misperceptions. Gu et al. (2018) 33 highlighted younger age and family history as key predictors of mastectomy choice, aligning with our findings. A 2023 study by Chettri et al. 34 emphasized the role of decision aids in reducing regret, reporting a 20% increase in BCS uptake when visual tools were used. Conversely, a 2020 study by Berlin et al. 25 noted that socioeconomic factors, particularly in the US, amplified mastectomy rates due to cost concerns, a trend less evident in universal healthcare systems. These studies reinforce the need for tailored communication strategies and decision support tools to align patient choices with clinical recommendations.

Oncoplastic techniques and reconstructive surgery advancements improve cosmetic outcomes, but access and awareness remain inconsistent 9. Limitations of this review include heterogeneity in outcome measures, reliance on observational studies 11,19, potential publication bias, and the restriction to studies published in English. Future research should focus on prospective studies and standardized outcome measures to better address patient decision-making.

CONCLUSIONS

The choice of mastectomy over BCS, despite MDT recommendations, is driven by fear of recurrence, body image concerns, psychological well-being, information processing, social influences, and radiotherapy burden 10-12. Enhanced communication, shared decision-making, and patient education are critical for aligning choices with MDT recommendations, improving satisfaction, and reducing decisional regret 19,22.

Conflict of interest statement

The author declares no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical consideration

Ethical approval was not required for this systematic review as it did not involve human participants or animal subjects. The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.

History

Received: May 22, 2025

Accepted: October 1, 2025

Figures and tables

Figure 1. Factors influencing mastectomy choice against MDT recommendations.

Study group % Choosing mastectomy Key characteristics
All patients 6-21% (median: 12.5%) Early-stage breast cancer
Age < 50 15-21% Higher recurrence anxiety
Family history 18-20% Genetic predisposition concerns
Table I. Prevalence of mastectomy choice against MDT recommendations.
Factor % of patients citing Primary study references
Fear of recurrence 60-80% 10 , 11 , 12
Body image concerns 30-40% 8 , 9 , 17
Psychological closure 25-35% 18 , 29
Radiotherapy burden 20-30% 5
Poor communication 15-25% 12 , 19-22 , 30 , 31
Social influences 41% 20
Decisional regret 10-15% 21 , 23
Cost (US) 18% 24 , 25
Cost (Italy & France) 3% 26 , 27
Table II. Key factors influencing mastectomy choice.
Country Out-of-pocket cost % choosing mastectomy (vs MDT) Main decision factors
USA High 10-15% Cost, recurrence anxiety, reconstruction access 24,25,36
Italy Minimal less than 2% Recurrence anxiety, MDT trust, body image 26,27,35,36
UK Minimal 8-14% Recurrence anxiety, MDT trust, body image 28,35,36
Canada Minimal 10-15% Recurrence anxiety, MDT trust 35,36
Table III. Cost and decision-making by country.

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Valerio Pasqualitto - UNISS, Sassari, Italy; Breast Surgery Unit of San Francesco Hospital, Nuoro, Italy. Corresponding author - valeriopasqualitto@gmail.com https://orcid.org/0000-0003-0142-9696

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[1]
Pasqualitto, V. 2025. Mastectomy versus breast-conserving surgery: a systematic review of factors influencing patient choice against multidisciplinary team recommendations. Plastic Reconstructive and Regenerative Surgery. 4, 1-2 (Oct. 2025), 19–24. DOI:https://doi.org/10.57604/PRRS-1366.
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