Understanding Patient Decision-Making in Breast Cancer Surgery: Risk Perception, Communication, and Psychosocial Influences

Background: Despite evidence discouraging contralateral prophylactic mastectomy (CPM) in average-risk patients, its use is increasing globally. While well-studied in Western settings, little is known about the factors influencing CPM decisions in the Middle East and North Africa (MENA) region. This study explores clinical, psychosocial, and communication-related factors associated with CPM choices among women with early-stage breast cancer. Methods: We conducted a retrospective study of 253 early-stage breast cancer patients who underwent mastectomy, with or without CPM, at the American University of Beirut Medical Center. Clinical and demographic data were extracted from medical records, and decision-making factors were assessed through tailored patient questionnaires. Associations were analyzed using chi-square tests and multivariable logistic regression. Results: Of the 253 women included in the study, 37 underwent CPM, while 216 had unilateral mastectomy (UM). Compared to the UM group, women who chose CPM were more likely to have a college education (96.9% vs. 57.6%, p < 0.001), be employed (69.7% vs. 41.3%, p = 0.002), and report a family history of breast cancer (55.6% vs. 30.2%, p = 0.003). Immediate reconstruction was significantly more common among CPM patients (67.6% vs. 16.4%, p < 0.001), and the 30-day rehospitalization rate was also higher (16.2% vs. 6.1%, p = 0.031). Women in the CPM group were more likely to prioritize extending life (84.6% vs. 56.7%, p = 0.007) and achieving peace of mind (80.8% vs. 49.3%, p = 0.003). Although all CPM patients cited risk reduction as a primary motivator, only 46.2% believed they had a lower recurrence risk than their peers (vs. 20% of UM patients, p < 0.001). Decisions to undergo UM were more frequently influenced by physicians’ recommendations (95.3% vs. 53.8%, p < 0.001), whereas CPM decisions appeared to be more patient-driven. Additionally, CPM patients reported more negative expectations and higher dissatisfaction with pain (57.7% vs. 32.0%, p = 0.012) and reconstructive outcomes (54.5% vs. 27.5%, p = 0.035). Conclusions: In this first study from the MENA region exploring CPM decision-making, choices were largely driven by personal preferences rather than clinical risk. These findings highlight the need for improved risk communication, shared decision-making, and broader integration of genetic counseling in surgical planning.