The clinical stakes are considerable. Breast cancer accounts for the largest proportion of cancer cases among women, and the pathway from suspicion of disease to diagnosis and surgical treatment generates tremendous psychological distress. Previous research indicates that between roughly 36 and 80 percent of patients undergoing breast-related procedures report moderate pre-operative anxiety, while 7 to 17.6 percent experience high levels. Qualitative work has shown that patients describe the experience as fighting an unknown, losing part of oneself, and adjusting to changes in physical appearance. Younger patients tend to suffer more, and a longitudinal study of 250 patients found that nearly 30 percent of those with high pre-operative anxiety continued to experience persistent anxiety after surgery and were more likely to develop new anxiety during subsequent treatments. Even less invasive procedures, such as ultrasound-guided vacuum-assisted biopsies performed under local anesthesia, can push distress to a clinical threshold, and higher pre-operative anxiety typically amplifies perceived pain during and after the operation.

Music-based interventions come in several forms, and the distinction matters. When medical staff administer passive music listening, it is called music listening as medicine; when musicians deliver it, it falls under other intervention types; and when a credentialed music therapist provides it, usually live and intertwined with verbal processing, it qualifies as music therapy. Systematic reviews have consistently supported the approach. A review of 26 randomized and quasi-randomized trials found music listening reduces pre-operative anxiety, while a meta-analysis in The Lancet reported that music lowered post-operative pain, anxiety, and analgesia use while raising satisfaction. A meta-analysis of 81 randomized controlled trials concluded that music interventions before, during, or after surgery significantly reduced anxiety and pain, with the greatest benefit observed when patients were offered a list of music options during selection. Studies in China have reported similar gains, including reduced inflammatory marker levels when music was combined with aromatherapy, and lower depression, anxiety, and shorter hospital stays when music listening was paired with progressive muscle relaxation after radical mastectomy.

What remained unknown, and what the Guangzhou team set out to investigate, was how patients themselves perceive these interventions and which implementation factors, such as duration, music selection, and the identity of the interventionist, actually drive the benefits. The researchers enrolled 40 patients undergoing breast-related procedures at Guangzhou Concord Cancer Center, where a music listening as medicine program had been embedded into the standard operative protocol since October 2023. Before the program launched, every nurse in the surgical department received training from a certified music therapist over an eight-month period, learning to select music according to the patient’s state and preference and to guide brief breathing exercises with music. Thirty-nine patients completed the post-operative electronic survey, which was deliberately administered only after surgery and the intervention, so that gathering feedback would not bias the care itself.

The intervention followed a structured four-step protocol. Upon entry into the operating room, each patient’s vital signs and anxiety level were assessed using a 0 to 10 visual analog scale. Music then played before the procedure and during anesthesia administration, resumed as the patient awakened from anesthesia, and a final assessment of vitals and anxiety took place right before discharge. The music library, pre-edited and pre-arranged by the music therapist in collaboration with trained nurses, mixed new age, light classical, and popular instrumental tracks chosen for relaxation and stress alleviation, with each piece scaled and rated for its overall energy level. Music played through a single in-ceiling speaker near the operating bed, with volume adjusted to patient comfort and ambient noise, ranging from 20 to 70 decibels. Patients could request their own music or let the nurses choose, though in practice all participants in the study had nurse-selected music.

The physiological and psychological results were striking. Patients showed an average decrease of nearly 3 points on the 10-point anxiety scale between the pre-operative and post-operative periods, a statistically significant reduction with a p-value below 0.001. Pre-operative heart rate and respiration rate both fell significantly, suggesting that music helped downregulate the sympathetic nervous system as patients awaited surgery. Post-operative heart rate also dropped significantly, indicating sustained relaxation during recovery. Intriguingly, however, both systolic and diastolic blood pressure rose during the post-operative period. The authors attribute this to residual surgical stress, discomfort, and the gradual reactivation of the autonomic nervous system after anesthesia, factors that may overwhelm music’s calming influence when patients are emerging from anesthesia with diminished consciousness and reduced cognitive processing of the music itself.

Perhaps the most counterintuitive finding concerned duration. Patients listened to music for an average of 57 minutes across the peri-operative period, roughly 25 minutes before surgery and 32 minutes after under general anesthesia. Yet the total listening time showed no significant correlation with anxiety reduction, procedural satisfaction, or music selection satisfaction. A piecewise regression analysis, which segmented listening time into 10-minute blocks, revealed that the most significant decrease in anxiety scores occurred within the 70-to-80-minute interval, a window that corresponds closely to an American study of mastectomy patients whose intervention spanned pre-, intra-, and post-operative phases with an average duration of 77.7 minutes. The authors caution that these preliminary results require confirmation, particularly since the pre- and post-operative contributions to that window could not be separated.

What did matter enormously was the music itself. Satisfaction with music selection correlated strongly and positively with satisfaction with the entire procedure, with a correlation coefficient of 0.766 and the selection variable explaining nearly 59 percent of the variance in procedural satisfaction. Over half of the participants reported no preference between self-selected and interventionist-selected music, and all had received nurse-selected music, suggesting that the quality and appropriateness of the selection, rather than who made it, drives satisfaction. A chi-square test further showed that patients with higher music satisfaction were more likely to perceive a clear function for music-based interventions in medical settings, hinting that patient understanding of the intervention shapes how satisfying they find it. Nearly 70 percent of participants believed the intervention should be delivered by trained interventionists, and more than 92 percent preferred simple music listening over other formats such as song discussion, instrument playing, singing, or composition.

The survey also mapped the barriers that could keep such programs from spreading. Although almost 90 percent of participants believed music interventions helped alleviate anxiety and induce relaxation, and 84.6 percent said such services should be offered in more hospitals across China, 69.2 percent cited accessibility of services and 53.8 percent cited financial constraints as obstacles to future use. Only about a third had even heard of music-based interventions before their hospital encounter, and fewer than 18 percent had ever tried one. When asked to define the intervention in their own words, ten participants could not articulate a definition despite positive experiences, describing it simply as feeling good to have music as an accompaniment, which underscores how unfamiliar the concept remains even among patients who benefit from it.

The study has clear limitations that the authors acknowledge: a small sample of 39 respondents, predominantly female and highly educated, no control group, a single site, and a mix of minor and major procedures that may dilute the findings. Live music therapy could not be assessed because those patients were excluded. Even so, the research offers a practical roadmap for hospitals considering music-based care. The recommendations are concrete: train the interventionists, curate selections with a music therapist, tailor the music to the patient’s peri-operative state, and pay close attention to the selection process itself, because how the music feels to the patient may matter more than how long it plays. As music-based interventions gain momentum in Chinese oncology, this study suggests the path forward runs through education, access, and the deceptively simple act of choosing the right song at the right moment.

Subject of Research: Therapeutic music listening for peri-operative anxiety and patient satisfaction in breast-related surgery in China

Article Title: Exploring patient health index, perceptions and satisfaction: the role of understanding music listening in peri-operative care for breast-related surgical procedures in China

Article References: He, Y.-L., Nhan, J., Chen, K.-J., & Qian, C.-N. (2026). Exploring patient health index, perceptions and satisfaction: the role of understanding music listening in peri-operative care for breast-related surgical procedures in China. Holistic Integrative Oncology, 5(1), Article 36. https://doi.org/10.1007/s44178-025-00170-8

Image Credits: AI Generated

DOI: 10.1007/s44178-025-00170-8

Keywords: peri-operative anxiety, music-based interventions, breast cancer surgery, music listening as medicine, patient satisfaction, Guangzhou Concord Cancer Center, nurse-delivered intervention, visual analog scale, autonomic nervous system, music selection, music therapy, China

Triple-negative breast cancer, often abbreviated TNBC, is the subtype that oncologists dread most. Unlike the majority of breast cancers, its cells lack the estrogen and progesterone receptors that make hormone therapy possible, and they do not overproduce the HER2 protein targeted by drugs such as trastuzumab. That leaves chemotherapy as the historical backbone of treatment, an approach that works for some patients but leaves others facing aggressive disease and limited options. Because TNBC tends to strike younger women and grows quickly, the stakes of getting treatment right before surgery, in the so-called neoadjuvant setting, are unusually high.

The neoadjuvant strategy itself is more than a logistical convenience. Giving systemic therapy before the surgeon’s knife allows clinicians to measure how the tumor responds, and the gold-standard benchmark is the pathologic complete response, or pCR: when pathologists examine the surgically removed tissue and find no residual invasive cancer at all. Achieving pCR is strongly associated with better long-term outcomes, including improved survival, which is why it has become the primary endpoint for most trials of neoadjuvant therapy in this disease. Randomized clinical trials, most prominently the KEYNOTE trials program, have already shown that adding pembrolizumab to neoadjuvant chemotherapy raises pCR rates in early-stage TNBC, and the drug has been approved for this indication in many countries.

But clinical trials, by design, enroll carefully selected patients who often differ from the broad population seen in oncology clinics. Older patients, those with multiple comorbidities, atypical tumor biology, and varied socioeconomic backgrounds are frequently underrepresented. What works in a trial may not translate seamlessly into the real world, where dosing delays, treatment interruptions, and patient heterogeneity are the norm rather than the exception. This gap between trial efficacy and real-world effectiveness is exactly what motivated a team of researchers led by Saad Arsalan Wasti of King Edward Medical University in Lahore, Pakistan, and Fatima Hajj of Lebanese University in Beirut, to systematically hunt down observational studies of pembrolizumab in routine practice.

The methodological machinery behind the new analysis was rigorous. The researchers searched four major biomedical databases, PubMed, Embase, Scopus, and the Cochrane Library, with the search updated through February 2026, capturing both prospective and retrospective cohort studies that compared neoadjuvant pembrolizumab plus chemotherapy against chemotherapy alone in patients with early-stage TNBC. Two reviewers independently screened the studies, extracted the data, and graded methodological quality using the Newcastle-Ottawa Scale, a standard tool for appraising non-randomized research. The pooled estimates were calculated with a random-effects model, which accounts for the statistical heterogeneity that inevitably arises when studies conducted in different settings with different populations are combined. The certainty of the resulting evidence was then formally appraised using the GRADE framework, the international standard for rating how much confidence clinicians can place in a body of evidence.

What emerged from the search was a modest but telling evidence base: five observational studies encompassing 1,501 patients, whose mean ages ranged from 49.5 to 57.8 years. When the data were pooled, the headline finding was striking. Patients who received pembrolizumab alongside their neoadjuvant chemotherapy had roughly one and a half times the likelihood of achieving a pathologic complete response compared with those who received chemotherapy alone, with a risk ratio of 1.52 and a 95 percent confidence interval of 1.29 to 1.80. Because the confidence interval sits entirely above 1.0, the result reaches conventional statistical significance, suggesting the association is unlikely to be a fluke of the small number of studies, even if the precise magnitude remains uncertain.

The surgical implications may prove just as consequential. The analysis found that pembrolizumab-treated patients were less likely to undergo axillary lymph node dissection, the removal of a large number of lymph nodes under the arm, with a risk ratio of 0.65. Axillary dissection is a procedure with real costs: it is a major driver of lymphedema, the chronic and sometimes disabling arm swelling that can follow breast cancer surgery, as well as numbness, shoulder dysfunction, and infection risk. If immunotherapy-driven tumor shrinkage allows more patients to avoid extensive node removal, that represents a tangible quality-of-life dividend beyond the tumor itself. Meanwhile, the review found no clear differences between the two groups in the time to first adjuvant therapy or in postoperative complications, an important signal that adding immunotherapy before surgery does not appear to complicate the surgical journey or delay subsequent treatment.

On the safety front, the picture was consistent with what is known about checkpoint inhibitors. The most frequently reported immune-related adverse events in patients receiving pembrolizumab were thyroid dysfunction and adrenal insufficiency, both reflecting the drug’s tendency to provoke the immune system against the body’s own endocrine organs. These effects are typically manageable with hormone replacement and careful monitoring, but they underscore why patients on checkpoint inhibitors require ongoing surveillance long after the infusion schedule ends. Notably, the analysis did not find a clear increase in perioperative complications, addressing one of the practical concerns that had lingered around delivering immunotherapy in the preoperative window.

Yet the researchers are emphatic that these findings deserve a heavy dose of humility. Using GRADE, they rated the certainty of evidence as very low for every outcome examined. The reasons are structural: observational studies are inherently vulnerable to confounding, selection bias, and residual imbalances between treatment groups, since patients who receive the newer drug may differ systematically from those who do not in ways that no statistical adjustment fully captures. Sample sizes were relatively small, follow-up durations varied, adverse-event reporting was inconsistent across studies, and the review was restricted to published data, meaning individual patient records were unavailable for deeper subgroup or adjustment analyses. The authors also registered the review prospectively on the Open Science Framework, a transparency measure that helps guard against outcome-switching but cannot compensate for the limitations of the underlying studies.

So where does this leave patients and clinicians? The most honest reading is that real-world experience so far mirrors the randomized trial evidence: pembrolizumab added to neoadjuvant chemotherapy in early-stage triple-negative breast cancer appears to boost the chances of a complete pathologic response, may spare some women extensive lymph node surgery, and does not obviously worsen surgical outcomes, all while carrying a predictable immune-related toxicity profile. That consistency across two very different kinds of evidence is reassuring, and for a disease with historically few targeted options, it matters. But the authors themselves caution that these results should not be interpreted as definitive. What the field needs next, they argue, is continued safety surveillance and well-designed comparative studies that can bring the rigor of randomization, or at least far more sophisticated adjustment, to the realities of routine care. Until then, the real-world story of pembrolizumab in TNBC remains a promising draft rather than a finished chapter, one that thousands of women and their physicians will be watching closely as the evidence matures.

Subject of Research: Real-world effectiveness and safety of neoadjuvant pembrolizumab plus chemotherapy in early-stage triple-negative breast cancer

Article Title: Real-world effectiveness and safety of neoadjuvant pembrolizumab in early-stage triple-negative breast cancer: a systematic review and meta-analysis

Article References: Wasti, S. A., Gill, S., Jamshed, A., Noor, M., Gill, N., Wasti, A., Waqas, S., Qayyum, T., Joseph, Y., Amin, F., Mohib, K., Khalid, A., Iqbal, M. U., Ur Rehman, M. S., & Hajj, F. (2026). Real-world effectiveness and safety of neoadjuvant pembrolizumab in early-stage triple-negative breast cancer: a systematic review and meta-analysis. BMC Cancer. https://doi.org/10.1186/s12885-026-17076-x

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17076-x

Keywords: triple-negative breast cancer, pembrolizumab, neoadjuvant therapy, immunotherapy, pathologic complete response, systematic review, meta-analysis, real-world evidence, immune-related adverse events, axillary lymph node dissection, breast cancer surgery, oncology

The study, published in Breast Cancer Research and Treatment, retrospectively analyzed 669 patients who underwent mastectomy at Shinshu University Hospital between January 2015 and December 2022. Because 20 of those patients had synchronous bilateral disease and were operated on both sides, the analysis covered a total of 709 breasts. Post-surgical bleeding, defined in the study as hemorrhage requiring manual compression or more than 100 milliliters of bloody discharge from a surgical drain by the morning of the first postoperative day, occurred in 42 cases, or 5.9 percent of the cohort. That figure may sound modest, but bleeding after mastectomy is clinically consequential: it can force blood transfusion or reoperation, prolong hospitalization, and delay adjuvant treatment.

What makes the new work distinctive is its focus on a regional rather than a systemic measure of body composition. Surgeons have long known that a high body mass index raises the odds of wound complications, infections, and bleeding after mastectomy, but BMI is a blunt instrument. It cannot distinguish a patient whose weight comes from abundant subcutaneous fat from one carrying substantial lean muscle. Meanwhile, surgical oncology research has increasingly implicated sarcopenia, the loss of skeletal muscle mass, in poor postoperative outcomes across many solid tumors. The standard tool for quantifying muscle in these studies is the skeletal muscle index, calculated from the cross-sectional muscle area at the third lumbar vertebral level on abdominal CT, normalized to height squared.

The Japanese team saw two problems with applying that abdominal measure to breast surgery. First, patients with early-stage breast cancer rarely undergo abdominal CT, so the necessary images often simply do not exist. Second, and more fundamentally, bleeding after mastectomy does not usually start in the abdomen. It originates from small vessels in the subcutaneous tissue or on the surface of the pectoralis major muscle, the very structures exposed during the operation. A global index of trunk musculature may therefore miss the local tissue characteristics that actually determine whether those fragile vessels hold or bleed. Chest CT, by contrast, is routinely obtained for staging in breast cancer, and the pectoralis major is clearly visualized on it.

To exploit that opportunity, the researchers measured the pectoralis major muscle area on axial CT slices at the level of the second thoracic vertebra, using semiautomated delineation within attenuation thresholds of minus 29 to 150 Hounsfield units. The area, expressed in square centimeters, was divided by the patient’s height squared to yield a pectoralis major muscle index, or PMI. Two investigators performed the image analysis while blinded to all postoperative outcomes, and cutoff values for BMI and PMI were derived from receiver operating characteristic curve analysis. The resulting thresholds were 23.7 for BMI and 2.90 for PMI.

The statistical signal was striking. Patients who bled had a significantly higher mean BMI than those who did not, 26.1 versus 22.8, and a significantly lower mean PMI, 2.76 versus 3.12. Yet BMI and PMI were only weakly correlated, with a Pearson coefficient of 0.16, and PMI also correlated only weakly with the conventional lumbar skeletal muscle index. In other words, the chest muscle measurement captures information about body composition that neither BMI nor the standard systemic muscle index reflects. On multivariate logistic regression, high BMI and low PMI each remained independently associated with bleeding, alongside the type of axillary procedure performed. Patients with a high BMI and low PMI had the highest incidence of bleeding at 20.1 percent, compared with 7.4 percent for high BMI with high PMI, 4.8 percent for low BMI with low PMI, and just 1.3 percent for low BMI with high PMI.

The authors offer a mechanistic explanation rooted in surgical anatomy. In patients with a high BMI, abundant subcutaneous fat can obscure small vessels and hinder meticulous hemostasis, raising the chance that a vessel is inadequately sealed and later bleeds. In patients with a low PMI, the pectoralis major itself tends to be atrophic, which may increase the fragility of the vessels running across its surface. Excess fat and diminished local muscle thus act synergistically: the fat makes vessels harder to secure, while the wasted muscle beneath makes them more vulnerable in the first place. Notably, the team’s earlier work found that the lumbar skeletal muscle index predicted bleeding only when normalized to BMI, a pattern consistent with sarcopenic obesity, whereas the regional PMI predicted bleeding on its own, without any adjustment.

One counterintuitive finding deserves mention. Faculty surgeons, defined as board-certified specialists, accounted for a significantly higher share of the bleeding cases than residents, 59.5 percent versus 42.2 percent. The authors argue this likely reflects case allocation rather than skill: faculty were more often assigned technically demanding or high-BMI patients, and at Shinshu every resident-performed mastectomy is directly supervised by a faculty surgeon acting as first assistant. Mastectomy is also a highly standardized procedure with routine drain placement and postoperative compression protocols, which may flatten differences attributable to individual technique. In routine practice, the study suggests, patient-related factors such as BMI and PMI matter more than operator-related ones.

The study has limitations the authors themselves acknowledge. It was retrospective and conducted at a single institution, the number of bleeding events was relatively small, and the bleeding definition captured early postoperative events rather than minor or late-onset ones. Bilateral cases were analyzed as independent observations, although sensitivity analyses excluding them produced essentially unchanged results. The BMI and PMI cutoffs were derived from the same cohort they were tested on, and the population was exclusively Japanese, so external validation in larger, more diverse cohorts will be needed before the thresholds can be generalized.

Even so, the practical implication is appealingly simple. Most breast cancer patients already have a preoperative chest CT, and measuring one muscle on an existing scan adds no cost, radiation, or delay. If validated prospectively, the pectoralis major muscle index could become a routine element of perioperative risk stratification, flagging patients, particularly those with both high BMI and low PMI, who warrant especially careful intraoperative hemostasis, closer drain monitoring, and a lower threshold for early intervention. In an era when body composition is increasingly recognized as a modifiable factor in cancer care, the study adds a new twist: for mastectomy outcomes, the muscle that matters most may be the one directly under the surgeon’s hands.

Subject of Research: Pectoralis major muscle mass as a predictor of post-surgical bleeding after mastectomy in breast cancer patients

Article Title: Low pectoralis major muscle mass predicts the risk of post-surgical bleeding after mastectomy in patients with breast cancer

Article References: Iji, R., Oba, T., Miyazawa, R., Kitazawa, A., Kiyosawa, N., Katsuyama, S., Morikawa, H., Amitani, M., Chino, T., Shimizu, T., Ono, M., Natori, K., Kanai, T., & Ito, K.-I. (2026). Low pectoralis major muscle mass predicts the risk of post-surgical bleeding after mastectomy in patients with breast cancer. Breast Cancer Research and Treatment, 219(1), Article 2. https://doi.org/10.1007/s10549-026-08063-8

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08063-8

Keywords: breast cancer, mastectomy, pectoralis major muscle index, post-surgical bleeding, body mass index, body composition, sarcopenia, computed tomography, surgical complications, risk stratification, perioperative care, Shinshu University

The headline finding is deceptively simple: CPM rates barely moved. In the earlier cohort, 19 percent of women had their healthy opposite breast removed at the time of cancer surgery; in the later cohort, the figure was 15 percent, a statistically significant but clinically modest decline that leaves roughly one in seven patients still undergoing a procedure that society guidelines explicitly discourage for average-risk women. The study period is particularly instructive because it brackets the 2016 consensus statement, which synthesized data showing that CPM produces only a small absolute reduction in contralateral breast cancer and no demonstrated survival benefit for most patients. Subsequent work has reinforced that message, including a 2024 analysis in JAMA Oncology reporting that bilateral mastectomy did not improve breast cancer mortality, and a Society of Surgical Oncology statement published the same year laying out narrow indications, outcomes, and risks for contralateral mastectomy. Yet the Kentucky and Minnesota data show that the practice, once entrenched, has proven resistant to guideline-driven de-escalation.

The technical details of the study design matter for interpreting these numbers. Because the analysis was a retrospective chart review rather than a randomized trial, it captures real-world practice patterns but cannot establish causation between the 2016 statement and any change in surgical behavior. The two cohorts were defined by diagnosis date, and the researchers evaluated not only CPM rates but also the uptake of genetic testing and the clinical and demographic factors associated with the decision to remove the contralateral breast. The institutions are both academic health systems, which typically have greater access to genetic counseling and multidisciplinary tumor boards than community hospitals, making the persistence of high CPM rates all the more notable. If guideline concordance is difficult to achieve in settings with robust resources, the authors suggest, the challenge in broader practice may be even greater.

The most dramatic change between the two eras was not in the operating room but in the genetics laboratory. Before 2016, only 2 percent of the women in the study underwent genetic testing; from 2016 onward, that figure rose to 22 percent. This eleven-fold increase reflects the second major consensus statement from the American Society of Breast Surgeons, published in 2019, which recommended that genetic testing be made available to all patients with breast cancer, not merely those meeting traditional family-history criteria. The expansion was enabled by broader panel testing that now screens for a growing list of moderate-penetrance genes such as ATM, CHEK2, and PALB2 in addition to the high-risk BRCA1 and BRCA2 genes. Wider testing has real clinical value, identifying carriers who benefit from intensified surveillance or risk-reducing surgery, but it has also complicated surgical decision-making, because the contralateral breast cancer risk associated with many moderate-risk variants remains imprecisely quantified.

Genetic testing emerged as one of the strongest factors associated with receiving a CPM in this cohort. That association cuts both ways. For women found to carry a pathogenic variant with a substantially elevated contralateral risk, such as BRCA1 or BRCA2, prophylactic removal of the unaffected breast is guideline-supported and can meaningfully reduce second cancer risk, as established by long-term studies of mutation carriers. But prior research has shown that testing results often arrive too late in the surgical pathway to change decisions, and that many women with negative test results still proceed with CPM. Studies of rapid preoperative testing have demonstrated that timely results can de-escalate surgery among carriers, yet the present findings suggest that in routine practice, testing more often accompanies, rather than redirects, the decision toward more extensive surgery. The authors point to this timing problem as a key target for intervention.

The demographic and tumor characteristics associated with CPM form a familiar but troubling pattern. Younger age at diagnosis, white race, lobular histology, increasing tumor size, and HER2 positivity all independently predicted receipt of the procedure. The age effect is consistent with a large body of literature showing that younger women more frequently overestimate their risk of a contralateral cancer and place greater weight on future risk when making surgical choices. The racial disparity is more concerning: prior national analyses have documented that white patients are disproportionately likely to undergo CPM even after accounting for clinical factors, raising questions about equitable counseling and access to reconstruction. The association with lobular histology likely reflects both the genuine difficulty of surveillance in lobular carcinoma, which is harder to detect mammographically, and the tendency of lobular cancers to be multifocal, which may amplify patient and physician concern about the opposite breast.

The persistence of CPM despite discouraging guidelines is not unique to this study. Analyses from the National Cancer Data Base and from state and national registries documented the steep rise of the procedure through the 2000s, and subsequent single-institution and multi-institution studies have repeatedly found that rates plateaued rather than fell after 2016. Research examining the effect of the American Society of Breast Surgeons guidelines specifically, including work published in Annals of Surgical Oncology and in Surgery, reached similar conclusions: the statements changed the conversation but not, for the most part, the operations. Patient-driven factors appear central. Surveys have shown that many women who choose CPM report high satisfaction with the decision, and studies of patient reactions to surgeon recommendations indicate that surgeon advice is only one input among many, with fear of recurrence and a desire for symmetry after reconstruction playing powerful roles.

The clinical stakes of this disconnect are considerable. CPM is a major operation that extends anesthesia time, increases the risk of surgical complications, lengthens recovery, and can compromise or delay reconstruction, all for a benefit that for average-risk women is largely psychological rather than survival-related. Quality-of-life studies comparing breast conservation with mastectomy and reconstruction have generally found comparable or better long-term outcomes with the less aggressive approach, and decision analyses have shown that the survival gain from CPM in average-risk women is measured in fractions of a percent. At the same time, the rise of multigene panel testing means that a minority of patients genuinely benefit from the procedure, which complicates blanket discouragement and may partly explain why surgeons remain reluctant to refuse a requested CPM outright. The clinical challenge is discriminating between the woman whose panel result justifies bilateral surgery and the woman whose fear, not genetics, is driving the request.

The authors are explicit that their findings should catalyze further work rather than close the question. They call for research to understand why CPM rates have remained stable across the guideline era and to identify interventions capable of reducing rates in average-risk women. Candidate strategies suggested by the broader literature include moving genetic testing earlier in the diagnostic pathway so that results can inform the initial surgical plan, standardizing risk counseling with validated tools that communicate contralateral risk in absolute rather than relative terms, and engaging surgeons in shared decision-making frameworks that acknowledge patient values while presenting the evidence clearly. Whether such interventions can succeed where consensus statements have not remains an open question, but the two-institution data provide a clear baseline: a decade after professional societies said the procedure should be rare, one in seven women was still having it.

For patients, the practical message is that a new breast cancer diagnosis is a moment when surgical decisions are made quickly and often under emotional strain, and that the evidence favors restraint for most women. A contralateral cancer diagnosed at an early stage is generally treatable, modern systemic therapies reduce contralateral risk further, and removing the healthy breast does not improve survival for the average patient. For women with documented pathogenic variants, the calculus is different and genetic counseling is essential. The study’s most valuable contribution may be its demonstration that guidelines alone do not change practice, and that closing the gap between evidence and the operating room will require changes to how, and how early, genetic information reaches the surgical decision.

Subject of Research: Trends in contralateral prophylactic mastectomy and genetic testing among women with unilateral breast cancer following society guideline publications

Article Title: Trends in contralateral prophylactic mastectomy and genetic testing in the era of new society guidelines

Article References: Reagan, A. M., Rutherford, C. R., Prathibha, S., Levy, B. E., Praska, C., Thacker, S. E., Kolbow, M., Ozed-Williams, B., Karnik, K. N., Mangino, A. A., Marmor, S., Tuttle, T. M., Hui, J. Y. C., & Burke, E. E. (2026). Trends in contralateral prophylactic mastectomy and genetic testing in the era of new society guidelines. Breast Cancer Research and Treatment, 219(3), Article 14. https://doi.org/10.1007/s10549-026-08073-6

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08073-6

Keywords: contralateral prophylactic mastectomy, breast cancer, genetic testing, BRCA, surgical guidelines, American Society of Breast Surgeons, unilateral breast cancer, genetic counseling, mastectomy rates, breast cancer surgery, hereditary cancer, surgical decision making