OBJECTIVES:
In hopes of avoiding future disease, some women at very high risk of developing breast cancer elect to have both breasts surgically removed, a procedure called bilateral prophylactic mastectomy. The surgery aims to remove all breast tissue that potentially could develop breast cancer. Preventive breast cancer surgery also may be considered if a woman has already had breast cancer and is therefore at increased risk for developing the disease again in either breast.
Is Prophylactic Mastectomy Effective?
A recent study suggests that prophylactic mastectomy may reduce the risk of breast cancer by as much as 90%. However, results vary widely. In some studies, women had prophylactic mastectomies for a variety of reasons, such as pain, fibrocystic breast disease, dense breast tissue, cancer phobia or a family history of breast cancer. Some women still developed breast cancer even though they had their breast tissue removed. But in most studies, patients did not develop breast cancer after prophylactic mastectomy. However, many of these patients would not have been considered high-risk for developing cancer.
Being identified as high risk doesn't mean the patient will get cancer, but it does mean that she'll have important decisions to make. One of which may be whether to have prophylactic (preventive) mastectomy — surgery to remove one or both breasts in hopes of preventing or reducing the risk of breast cancer. Some experts argue that even for high-risk women, prophylactic mastectomy is inappropriate because not all breast tissue can be removed during a surgical procedure. To understand why, we need to know what comprises breast tissue and where cancer originates.
Where Does Cancer Come From?
Breast cancers may develop in the glandular tissue of the breast, specifically in the milk ducts and the milk lobules. These ducts and lobules are located in all parts of the breast tissue, including tissue just under the skin. The breast tissue extends from the collarbone to the lower rib margin, and from the middle of the chest, around the side and under the arm.
In a breast skin-conserving mastectomy, it is necessary to remove tissue from just beneath the skin down to the chest wall and around the borders of the chest. However, even with very thorough and delicate surgical techniques, it is impossible to remove every milk duct and lobule, given the extent of the breast tissue and the location of these glands just beneath the skin.
Who Should Have a Prophylactic Mastectomy?
Does this mean that every patient should consider breast cancer prevention surgery? The answer is clearly no. The decision to proceed with prophylactic mastectomy is an individual decision. Such factors as an estimation of individual breast cancer risk, the ability to monitor the patient for early breast cancer and, most importantly, the patient's concerns and feelings need to be considered in making this decision.
According to the American Cancer Society, only those women who are at very high risk of breast cancer should even consider surgery.
This includes women with one or more of the following risk factors:
Mutated BRCA genes.
Previous cancer in one breast and a strong family history of breast cancer.
History of lobular carcinoma in situ (LCIS).
Prophylactic mastectomy should only be considered after the patient has received the appropriate genetic and psychological counseling to discuss the psychosocial impacts of the procedure.
Emotional effects of mastectomy
The decision to have a prophylactic mastectomy is a difficult one, but it isn't an urgent decision. Taking six months to a year to decide to pursue this type of surgery is appropriate. The patient should discuss her concerns and feelings with a psychologist even if she feels she is not struggling with the decision.
If the patient has a high risk of breast cancer, a prophylactic mastectomy might make her feel better about her future because it can significantly reduce the risk. She might spend less time worrying about her health after the procedure and continue with a productive life.
The majority of women who undergo prophylactic mastectomy are satisfied with their choice. Those who regret their decision may feel this way because of complications with their breast implants or dissatisfaction with their appearance after the procedure. In addition, women who choose surgery primarily because their doctors recommended it may be more likely to regret their decision.
Other options
If you're at high risk of breast cancer and you decide against prophylactic mastectomy, you do have other options:
Surveillance:
The goal of surveillance is to detect any possible cancer at its earliest stage.
Breast self-exam every month beginning at age 20
Clinical breast exams once or twice a year
Annual mammograms may be recommended when you're 25 to 35.
If you have a family history of breast cancer that doesn't seem to be related to a mutation in BRCA1 or BRCA2, annual mammograms about five to 10 years before the age at which your youngest affected first-degree relative was diagnosed with breast cancer or by age 40 whichever comes first
Chemo-preventive drug therapy:
This prevention method uses drugs to prevent cancer.
Tamoxifen, a drug used to prevent recurrence in women who have already had cancer, can also be used as a preventive or risk-reducing measure for high-risk women. Side effects include hot flashes, vaginal discharge, an increased chance of endometrial cancer and blood clots
Raloxifene is a similar drug to tamoxifen with has side some similar effects, but raloxifene isn't linked to endometrial cancer.
What Are My Options for Surgery?
For women who choose prophylactic mastectomy, several new and important surgical options have become available.
It is now possible to remove breast tissue using skin-sparing techniques in which the underlying breast tissue is removed from just under the skin and down to the chest wall. This technique removes the vast majority of the glands where breast cancer may be more likely to develop. The nipple and surrounding tissue, the areola, are also removed because the ducts converge toward the nipple, creating a concentrated area of duct tissue. However, the skin of the breast is spared, preserving the breast skin envelope.
When skin-sparing mastectomy is combined with immediate breast reconstruction, the results can be excellent. Women who choose prophylactic mastectomy, often combined with immediate reconstruction, are very pleased not only with their choice but also the reconstruction.
The doctor may recommend a simple (total) mastectomy, which removes the breast tissue, nipple, the areola and some of the overlying skin. Removing the entire breast is preferred because it allows the surgeon to cut out as much breast tissue as possible.
Breast reconstruction surgery:
Reconstruction surgery won't restore normal sensation to the breasts. And although breast reconstruction has advanced in many ways, chances are the reconstruction won't look exactly like the natural breast tissue. However, the contour of the new breasts can usually be restored so that the silhouette looks similar to the natural breasts.
Breast reconstruction isn't for everyone. The patient may prefer artificial (prosthetic) breast mounds that can be worn externally. This helps the figure look more natural after mastectomy.
Different approaches to breast reconstruction include:
Using breast expanders or implants
Using your body's own tissue (Tramflap)
Using a combination of tissue reconstruction and implants
SUMMARY:
Only women with a high risk of developing breast cancer are candidates for prophylactic mastectomy, and the decision can be difficult to make. Researching the options and talking with professionals can give the patient information needed to decide whether prophylactic mastectomy is right for her. While surgery is not an approach that should be advocated for all high-risk individuals, it can be very important for appropriately selected women.
Prophylactic mastectomy is a controversial and awkward issue. It is a difficult decision for both patient and care-giver. If we ignore the subject and do not arm ourselves with the proper information and the whole truth we can leave our patient alone and uneducated with a complicated and difficult dilemma.
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