Emily Bellavance, M.D. 22 S.

Greene Street S4B05 Baltimore, MD 21201

Dear Doctor, I am inviting you to participate in a research project to study Surgeons' Perspectives of Decision Making in Contralateral Prophylactic Mastectomy. Your participation in this study entails filling out the enclosed survey which will take 5-7 minutes of your time. Your responses are voluntary and anonymous. Results of the survey may be used for publication. Enclosed is a two dollar bill as a token of appreciation for participating in this study. Thank you for your time and for sharing your thoughts on the use of contralateral prophylactic mastectomy in the treatment of breast cancer. Sincerely,

Emily Bellavance, M.D. University of Maryland Medical 22 S. Greene Street Room S4B05 Baltimore, MD 21201

Emily Bellavance, M.D. 22 S. Greene Street S4B05 Baltimore, MD 21201

Emily Bellavance, M.D. Assistant Professor of Surgery Division of General & Oncologic Surgery Department of Surgery University of Maryland School of Medicine 22 South Greene Street, Rm S4B05 Baltimore, MD 21201

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please complete the survey below:

1. Which one of the following best describes your work setting? University/teaching hospital Private practice Other (please specify) 2. Which of the following best describes your professional activity? Greater than 50% time allocated to research Greater than 50% time allocated to clinical duties Other (please specify)

11. Please rate your agreement with the following statement: In patients with NO additional risk factors for contralateral breast cancer, the side effects of a second mastectomy are generally not worth the benefits. Strongly agree Somewhat disagree Somewhat agree Strongly disagree Neutral 12. In your practice, do you ROUTINELY use any of the following to help patients make an informed decision about prophylactic contralateral mastectomy (you can choose more than one)? Consultation with a radiation oncologist Consultation with a medical oncologist Web-based educational material Written educational material Consultation with a genetic counselor Consultation with a counselor trained in psycho-oncology Other (please specify) 13. Please rate the following methods to help patients make an informed decision about prophylactic contralateral mastectomy.

requiring mastectomy for complete excision. She has no family history of breast cancer. After a discussion of her prognosis, including her risk of recurrence and development of a contralateral breast cancer, she requests a bilateral mastectomy because she does not want to die of breast cancer. I am comfortable with proceeding with surgery I am somewhat uncomfortable with proceeding with surgery I am very uncomfortable with proceeding with surgery I would decline to perform the surgery 17. A 40 year old woman presents with multifocal DCIS of the right breast requiring mastectomy for complete excision. She has no family history of breast cancer. After a discussion of her prognosis, including her risk of recurrence and development of a contralateral breast cancer, she requests a bilateral mastectomy for the purpose of achieving a more symmetrical reconstruction. I am comfortable with proceeding with surgery I am somewhat uncomfortable with proceeding with surgery I am very uncomfortable with proceeding with surgery I would decline to perform the surgery

16. A 40 year old woman presents with multifocal DCIS of the right breast

3. How many years have you been in practice? ______ 4. How old are you? ________ 5. What proportion of your practice is devoted to the treatment of breast disease? <20% 20-50% 50-80% > 80% 6. Please indicate your gender. Male Female 7. Please estimate the number of contralateral prophylactic mastectomies you have performed in the last year None Fewer than 10 11-20 21-50 >50 8. Please choose reasons you would initiate a discussion about contralateral mastectomy.. You may choose more than one. Family history Difficult surveillance Cosmesis (symmetry) Unilateral mastectomy Young age Genetic predisposition (BRCA) Lobular histology Other (please specify)

Extremely helpful

Somewhat helpful

Not helpful

Consultation with a radiation oncologist Consultation with a medical oncologist Web-based educational material Written educational material Consultation with a genetic counselor Consultation with a counselor trained in psycho-oncology

18. A 40 year old woman presents with a single focus of DCIS amenable to breast conservation. She has no family history of breast cancer. After a discussion of her prognosis, including her risk of recurrence and devel opment of a contralateral breast cancer, she requests a bilateral mastectomy because she is worried about developing another breast cancer." I am comfortable with proceeding with surgery I am somewhat uncomfortable with proceeding with surgery I am very uncomfortable with proceeding with surgery I would decline to perform the surgery 19. With a patient with NO increased risk of developing a contralateral breast cancer, I discuss her risk most commonly by using Percentages to describe risk (example 10% over time) General description of risk (high risk versus low risk) Percentages to describe the likelihood of NOT developing a new breast cancer General description of the likelihood of NOT developing a new breast cancer 20. With a patient with an ACTUAL increased risk of developing a contralateral breast cancer, I discuss her risk most commonly by using Percentages to describe risk (example: 10% over time) General description of risk ( high risk versus low risk) Percentages to describe the likelihood of NOT developing a new breast cancer General description of the likelihood of NOT developing a new breast cancer

Other (please specify)

9. In discussing the surgical management of breast cancer, contralateral mastectomy is most commonly initiated by Surgeon Patient family Patient Plastic surgeon Other physician

14. Please rate your agreement with the following statement: Delaying contralateral mastectomy until the time of final reconstruction would help patients make an informed decision about prophylactic contralateral mastectomy. Strongly agree Somewhat disagree Somewhat agree Strongly disagree Neutral 15. A 40 year old woman with a pathologic BRCA 1 mutation presents with an early stage operable breast cancer. After discussion of her prognosis, including risk of breast cancer recurrence and development of contralateral breast cancer, she requests bilateral mastectomies because I am worried about developing another breast cancer." I am comfortable with proceeding with surgery I am somewhat uncomfortable with proceeding with surgery I am very uncomfortable with proceeding with surgery I would decline to perform the surgery

10. Please pick the top 3 reasons patients chose contralateral prophylactic mastectomy in your practice Actual increased risk Avoid future imaging/biopsies Perceived increased risk Mistrust of surveillance Cosmesis/symmetry Physician recommendation Other (please specify)