Prophylactic Mastectomy - is it right for you?

Having prophylactic mastectomy is a very personal choice. There is no "right answer", only what you consider is best for you.

Women who are at high risk of developing breast cancer have the option of prophylactic (preventive) mastectomy as a way of decreasing their risk. Factors that increase a woman’s chance of developing breast cancer include:

1. a genetic predisposition to breast cancer e.g. BRCA+, Cowden's Syndrome, Li-Fraumeni Syndrome
2. a strong family history of breast cancer
3. a breast cancer diagnosis at a young age
4. abnormal breast cells on biopsy that increase the risk of breast cancer, e.g. LCIS
5. a history of previous chest radiation, e.g. treatment for Hodgkin's Lymphoma

Prophylactic mastectomy decreases the risk of future breast cancer by 97-99%. Since the breast tissue is removed, the surgery also removes the need for regular screening mammograms/MRIs and preventive drugs like tamoxifen.

Surgery is not the only option however. Many women prefer close monitoring and preventive drugs (known as "chemoprophylaxis").

Regardless of other choices, all women should modify their diet wherever possible to decrease their risk. It is vital you discuss all your options and the pros, cons, and risks of each before making the best decision for you.

If you choose prophylactic surgery please remember that you can also have breast reconstruction at the same time as mastectomy. There is no need to experience having a flat chest unless you specifically decide you wish to remain without breasts.

You have several reconstructive options and the results can be very natural and cosmetic. If you choose to undergo breast reconstruction at the same time, a "skin-sparing" mastectomy is usually performed. This saves all the breast skin envelope which significantly adds to the cosmetic results without increasing your risk of cancer. In many cases, the nipple-areola can be saved too. This is known as a "nipple-sparing" mastectomy.

Thankfully, most insurance plans cover the cost of prophylactic mastectomy and reconstruction in high risk patients but you will have to check with your individual plan to make 100% sure.

I hope this info helps.

Dr C

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PRMA Plastic Surgery specializes in state-of-the-art breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. We are In-Network for most US insurance plans and routinely welcome patients from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients at facebook.com/PRMAplasticsurgery.

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When is Prophylactic Mastectomy The Right Choice?

Having breast cancer in one breast increases a woman's chances of getting breast cancer in the second breast at some point in her lifetime. A study in the March issue of Cancer addresses a question which women facing mastectomy for breast cancer have been asking doctors for years.... should I have my other ("good") breast removed as well to decrease my risk of future breast cancer in the other breast? Here's the study abstract....

"Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy."
Min Yi, Funda Meric-Bernstam, Lavinia P. Middleton, et al. CANCER Print Issue Date: March 1, 2009

BACKGROUND:
Although contralateral prophylactic mastectomy (CPM) reduced the risk of contralateral breast cancer in unilateral breast cancer patients, it was difficult to predict which patients were most likely to benefit from the procedure. The objective of this study was to identify the clinicopathologic factors that predict contralateral breast cancer and thereby inform decisions regarding performing CPM in unilateral breast cancer patients.

METHODS:
A total of 542 unilateral breast cancer patients who underwent CPM at The University of Texas M. D. Anderson Cancer Center from January 2000 to April 2007 were included in the current study. A logistic regression analysis was used to identify clinicopathologic factors that predict contralateral breast cancer.

RESULTS:
Of the 542 patients included in this study, 25 (5%) had an occult malignancy in the contralateral breast. Eighty-two patients (15%) had moderate-risk to high-risk histologic findings identified at final pathologic evaluation of the contralateral breast. Multivariate analysis revealed that 3 independent factors predicted malignancy in the contralateral breast: an ipsilateral invasive lobular histology, an ipsilateral multicentric tumor, and a 5-year Gail risk 1.67%. Multivariate analysis also revealed that an age 50 years at the time of the initial cancer diagnosis and an additional ipsilateral moderate-risk to high-risk pathology were independent predictors of moderate-risk to high-risk histologic findings in the contralateral breast.

CONCLUSIONS:
The findings indicated that CPM may be a rational choice for breast cancer patients who have a 5-year Gail risk 1.67%, an additional ipsilateral moderate-risk to high-risk pathology, an ipsilateral multicentric tumor, or an ipsilateral tumor of invasive lobular histology.

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So what does all this mean?

This study basically concludes that prophylactic (ie preventive) mastectomy should be recommended to breast cancer patients in the following situations:

1) the breast cancer is particularly aggressive or invasive

2) the biopsy pathology report shows high risk histology (such as "invasive lobular" disease)

3) there are multiple tumors in the same breast

4) a 5-year Gail risk of at least 1.67 - The "Gail risk" assesses a woman's risk of developing breast cancer by looking at a number of health factors including her medical history, race, age and more.

5) age 50 or older at the time of the first breast cancer diagnosis

This study is helpful. I'd like to expand a little on the effect age has on risk of future disease. Many doctors (including myself) recommend prophylactic mastectomy to young women, particularly if they have a family history of breast cancer, as these women have the highest overall risk of getting another cancer in their lifetime. Previous studies have shown that breast cancer patients have close to a 1% risk of another cancer per year. This risk is cumulative, in other words, it adds up: 1 % risk after 1 year, 10% risk after 10 years, 30% after 30 years, and so on. This cumulative risk is important to remember.

While I applaud this study and think it's results are very useful, I also think it is imperative that doctors remember the primary indication for prophylactic mastectomy: the patient's wishes. Breast cancer is such a devastating disease both physically and emotionally. We can educate our patients all we want about study results but we must not forget the erosive nature of anxiety over the possibility of a second breast cancer in the future. If one of my patients wants a prophylactic mastectomy even after discussing the studies, that's good enough for me.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in "natural" breast reconstruction surgery after mastectomy using the patient's own tissue (including DIEP flap reconstruction). PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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