Prophylactic mastectomy: An option for breast cancer prevention

If you have relatives who have been diagnosed with breast cancer, you might wonder about your risk for the disease and whether you can take steps to reduce it. Your level of risk — evaluated and determined by your doctor — depends on your personal medical and reproductive history, your family history, your genes and even environmental and lifestyle exposures.

Being identified as high risk doesn't mean you'll get cancer, but it does mean that you'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 your risk of breast cancer.

Why choose prophylactic mastectomy: Risks and prevention

The truth is that all women are at risk of breast cancer just by being female. But some factors can increase your chances of the disease. Your level of risk depends on your personal medical history, your family history and your genes. You might be considered high risk for breast cancer and a candidate for prophylactic mastectomy if you have:

• Already had cancer in one breast. If you develop breast cancer and have a strong family history of the disease, you may decide to have both breasts removed. One breast is removed to get rid of the cancer, and the other is removed to prevent the possibility of developing cancer in your unaffected breast later.
• A family history of breast cancer. If you have two or more close family members — mother, sister, daughter, aunt, grandmother — who have had breast cancer before age 50 or during her premenopausal years, you have a significant family history of breast cancer. A predisposition to breast cancer can be passed on to you through your mother's or father's side of the family. If you have a family history of the disease, prophylactic mastectomy can reduce your chance of developing the disease by 90 percent.
• Positive results from gene testing. Genes are the blueprints that determine how your body grows and functions. Genetic testing can identify if you have mutations (alterations) in genes that increase your risk of breast cancer or other cancers such as ovarian and colon cancer. If genetic testing has shown that you have a mutation in genes associated with breast cancer (BRCA1 or BRCA2), you have a 55 percent to 85 percent chance of developing breast cancer by age 70. A prophylactic mastectomy to remove both breasts can significantly reduce your chances of developing breast cancer.
• Early signs of cancer in your breast. Your doctor may have discovered precancerous or abnormal cells in the milk-producing glands (lobules) of your breast (lobular carcinoma in situ). These findings are not cancers, but are markers of an increased risk of developing breast cancer.

Your doctor determines whether you're at high risk of breast cancer based on these factors and other prediction methodology. A discussion with a genetic counselor is usually recommended before making your decision. Meeting with a breast surgeon and plastic surgeon beforehand to discuss potential risks and benefits of surgery is beneficial. In addition, you may find seeking evaluation or management options by a breast health specialist helpful.

Though a prophylactic mastectomy reduces your risk of breast cancer, it doesn't guarantee that you won't develop the disease. Breast tissue is widely distributed on your chest wall. Sometimes it can be found in your armpit, above your collarbone or on the upper part of your abdominal wall. For that reason, no mastectomy can guarantee that all of your breast tissue will be removed, and any remaining tissue can still develop breast cancer.

Breast anatomy

Breast anatomy

Abnormal or precancerous cells in your ducts or milk-producing glands (lobules) could mean you have an increased risk of breast cancer later.

Close

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. You may even wish to discuss your concerns and feelings with a psychologist if you're struggling with the decision.

If you have a high risk of breast cancer, a prophylactic mastectomy might make you feel better about your future because it can significantly reduce your risk. You might spend less time worrying about your health after your mastectomy.

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.

Deciding not to have surgery: 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. If you have positive results from gene testing, your doctor may recommend you do a breast self-exam every month beginning in your early 20s. Your doctor may also recommend clinical breast exams once or twice a year beginning in your mid-20s. 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, your doctor may recommend you begin 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). For example, if your mother had breast cancer at 40, you'd start your mammograms at 30 or 35.

• Chemopreventive 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. Scientists are also studying the effectiveness of raloxifene as preventive therapy. Raloxifene has side effects similar to tamoxifen, but raloxifene isn't linked to endometrial cancer.

Prophylactic mastectomy: The surgical procedure

Your doctor may recommend a simple (total) mastectomy, which removes the breast tissue, nipple, the pigmented area around your nipple (areola) and some of the overlying skin. Removing your entire breast is preferred because it allows the surgeon to cut out as much breast tissue as possible.

After a prophylactic mastectomy, many women choose breast reconstruction surgery. Different approaches to breast reconstruction include:

• Using breast expanders or implants
• Using your body's own tissue (autologous tissue reconstruction)
• Using a combination of tissue reconstruction and implants

Reconstruction surgery won't restore normal sensation to your breasts. And although breast reconstruction has advanced in many ways, chances are your new breasts won't look exactly like your natural ones. However, the contour of your new breasts can usually be restored so that your silhouette looks similar to your natural breasts.

Breast reconstruction isn't for everyone. You may prefer artificial (prosthetic) breast mounds that can be worn in your bra. These help your figure look more natural after your mastectomy.

A difficult decision

Only women with a high risk of developing breast cancer are candidates for prophylactic mastectomy, and the decision can be difficult to make. Researching your options and talking with your doctor can give you the information you need to decide whether prophylactic mastectomy is right for you.