Preventive mastectomy

Last updated
Preventive mastectomy
Specialty general surgeon/plastic surgeon

A preventive mastectomy or prophylactic mastectomy or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced. [1] [2]

Contents

Indications

The procedure is a surgical option for individuals who are at high risk for the development of breast cancer. High risk women without a prior history of personal breast cancer might consider bilateral risk-reducing mastectomy (BRRM) as an option for minimising the risk of primary breast carcinoma development. [3] The procedure includes the surgical removal of both breasts before any pathologic diagnosis has been made. Women that were previously diagnosed with a breast cancer in one breast (ipsilateral breast cancer) might elect to undergo risk-reducing mastectomy of the other unaffected (contralateral) breast, that is to say contralateral risk-reducing mastectomy (CRRM), to minimize the risk of a second breast cancer development. CRRM has been shown to reduce the incidence of contralateral breast cancer, but there is not sufficient evidence that it improves survival. [4] Women who had a bilateral mastectomy in 2013 were about 10 years younger than those who had a unilateral mastectomy. [5]

This preventive operation pertains to women with these characteristics: [2]

Discussions and decision should be made with the help of specialists who can use relevant information and statistical models to predict the individual lifetime risk of development of breast cancer.

Undergoing a preventive mastectomy does not guarantee that breast cancer will not develop later, however, it reduces the risk by 90% in high risk women. [2] [8] Also, a preventive mastectomy may not be able to remove all breast tissue as some of it may be in the arm pit, near the collar bone, or in the abdominal wall. [1]

Male carriers of BRCA1 and BRCA2 mutations have a higher risk of breast cancer than other males, approximately 1.2% and 6.8%, [9] but their risk is much lower than in female mutation carriers (about 60%) and lower than in the general female population (12%). [10] Thus, preventive mastectomy has not been advocated for affected men.

Procedure

In most situations the operation involves both breasts and thus represents a bilateral procedure. When cancer has affected already one breast, the other breast, still healthy, may be removed in a unilateral preventive mastectomy. Typically either a simple, a subcutaneous or a nipple-sparing mastectomy is performed. With the former the areola and nipple are removed, while the other two approaches preserve the nipple area for cosmetic reasons. To increase the viability of the nipple area for preservation during mastectomy, a so-called "nipple delay" procedure can be done several weeks before the mastectomy. [11] Reconstructive breast surgery can be performed in the same surgical setting, added after the mastectomy. [12] Saline or silicone implants may be used in the reshaping process and may be placed in a later setting. [13]

A preventive mastectomy carries certain risks including those of anesthesia, bleeding, infection, pain, disfiguration, anxiety and disappointment.

After surgery, routine screening for breast cancer is recommended. [2]


Alternatives

There are other options to reduce the risk of future breast cancer. [2] Intensified breast cancer screening for high risk women may detect cancer at an early, treatable stage. Certain medications that block the effect of estrogen (i.e. tamoxifen, raloxifen, exemestane) can reduce the risk by about 50% but also have side effects. Prophylactic salpingo-oophorectomy reduces estrogen levels and the risk of both ovarian and breast cancer, however, the reduction in breast cancer risk is about 50% in high risk women [8] as compared to 90% when preventive mastectomy is done. Lifestyle changes (in weight, diet, exercise, avoidance of smoking, limiting alcohol) may reduce the risk to some degree. [14]

Acceptance

A factor that facilitates the decision to undergo a preventive mastectomy is that results of breast reconstructive surgery have improved. [15] A 2004 Canadian study found that 70% of women were satisfied or extremely satisfied with the reconstruction after bilateral prophylactic mastectomy. [12] In the United States preventive mastectomy is gaining increased acceptance. [15] [16] The decision of famous actresses such as Christina Applegate and Angelina Jolie [13] to undergo preventive mastectomy has given the procedure wider media attention. [15] The trend towards prophylactic mastectomy appears to be less pronounced in Europe [15] and India. [17]

Related Research Articles

<span class="mw-page-title-main">Breast reconstruction</span> Surgical rebuilding of a breast

Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

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<span class="mw-page-title-main">Mammaplasty</span> Surgically modifying the appearance of the breast

Mammaplasty refers to a group of surgical procedures, the goal of which is to reshape or otherwise modify the appearance of the breast. There are two main types of mammoplasty:

  1. Augmentation mammaplasty is commonly performed to increase the size, change the shape, and/or alter the texture of the breasts. This usually involves the surgical implantation of breast implant devices.
  2. Reduction mammaplasty is commonly performed to reduce the size, change the shape, and/or alter the texture of the breasts. This involves the removal of breast tissue.

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<span class="mw-page-title-main">Hereditary breast–ovarian cancer syndrome</span> Medical condition

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<span class="mw-page-title-main">PALB2</span> Protein-coding gene in the species Homo sapiens

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<span class="mw-page-title-main">Male breast cancer</span> Medical condition

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<i>BRCA</i> mutation Medical condition

A BRCA mutation is a mutation in either of the BRCA1 and BRCA2 genes, which are tumour suppressor genes. Hundreds of different types of mutations in these genes have been identified, some of which have been determined to be harmful, while others have no proven impact. Harmful mutations in these genes may produce a hereditary breast–ovarian cancer syndrome in affected persons. Only 5–10% of breast cancer cases in women are attributed to BRCA1 and BRCA2 mutations, but the impact on women with the gene mutation is more profound. Women with harmful mutations in either BRCA1 or BRCA2 have a risk of breast cancer that is about five times the normal risk, and a risk of ovarian cancer that is about ten to thirty times normal. The risk of breast and ovarian cancer is higher for women with a high-risk BRCA1 mutation than with a BRCA2 mutation. Having a high-risk mutation does not guarantee that the woman will develop any type of cancer, or imply that any cancer that appears was actually caused by the mutation, rather than some other factor.

Professor Kefah Mokbel FRCS is currently the chair of breast cancer surgery and the multidisciplinary breast cancer program at the London Breast Institute of the Princess Grace Hospital part of HCA Healthcare, Professor (Honorary) of Breast Cancer Surgery at Brunel University London, an honorary consultant breast surgeon at St George's Hospital. Kefah Mokbel is the founder and current president of Breast Cancer Hope; a UK-based charity "dedicated to improving the quantity and quality of life in women diagnosed with breast cancer". He was appointed as a substantive consultant breast surgeon at St George's Hospital NHS trust in February 2001. He was named in Tatler magazine's Best Doctors Guide as one of the featured "Top Breast Surgeons" in 2006, 2007 and 2013. In November 2010 he was named in the Times magazine's list of Britain's Top Doctors.

Kristi Funk is an American breast cancer surgeon known for her surgical treatment of celebrities Angelina Jolie and Sheryl Crow and her advocacy of whole-food plant-based nutrition.

<span class="mw-page-title-main">High-grade serous carcinoma</span> Medical condition

High-grade serous carcinoma (HGSC) is a type of tumour that arises from the serous epithelial layer in the abdominopelvic cavity and is mainly found in the ovary. HGSCs make up the majority of ovarian cancer cases and have the lowest survival rates. HGSC is distinct from low-grade serous carcinoma (LGSC) which arises from ovarian tissue, is less aggressive and is present in stage I ovarian cancer where tumours are localised to the ovary.

<span class="mw-page-title-main">Prophylactic salpingectomy</span> Surgical technique

Prophylactic salpingectomy is a preventative surgical technique performed on patients who are at higher risk of having ovarian cancer, such as individuals who may have pathogenic variants of the BRCA1 or BRCA2 gene. Originally salpingectomy was used in cases of ectopic pregnancies. As a preventative surgery, however, it involves the removal of the fallopian tubes. By not removing the ovaries this procedure is advantageous to individuals who are still of child bearing age. It also reduces risks such as cardiovascular disease and osteoporosis which are associated with the removal of the ovaries.

Prophylactic surgery, is a form of surgery whose purpose is to minimize or prevent the risk of developing cancer in an organ or gland that has yet to develop cancer and is known to be at high risk of developing cancer. This form of preventive healthcare may include surgeries such as mastectomies, oophorectomies, colectomies and surgical corrections, such as the surgical correction of cryptorchidism or undescended testis. Another less common definition of prophylactic surgery also includes the prevention of other diseases, outcomes or even future appearance.

<span class="mw-page-title-main">Breast and ovarian cancer</span>

Breast and ovarian cancer does not necessarily imply that both cancers occur at the same time, but rather that getting one cancer would lead to the development of the other within a few years. Women with a history of breast cancer have a higher chance of developing ovarian cancer, vice versa.

<span class="mw-page-title-main">SEE-FIM Protocol</span> Pathology protocol to assess cancer risk

The SEE-FIM protocol is a pathology dissection protocol for Sectioning and Extensively Examining the Fimbria (SEE-FIM). This protocol is intended to provide for the optimal microscopic examination of the distal fallopian tube (fimbria) to identify either cancerous or precancerous conditions in this organ.

<span class="mw-page-title-main">Nipple-sparing mastectomy</span> Breast cancer treating method

Nipple-sparing mastectomy (NSM), also known as nipple delay, is one of the surgical approaches for treating or preventing breast cancer. It involves the removal of all breast tissue, except the nipple-areolar complex (NAC), and the creation of new circulatory connections from the breast skin to NAC. By preserving the NAC, NSM has provided patients with higher cosmetic expectations and the opportunity to undergo a mastectomy while maintaining a more natural appearance.

References

  1. 1 2 Mayo Clinic staff. "Prophylactic mastectomy: Surgery to reduce breast cancer risk". Mayo Clinic . Retrieved 2013-05-14.
  2. 1 2 3 4 5 NIH staff. "Preventive Mastectomy". National Cancer Institute . Retrieved 2013-05-14.
  3. ↑ Eisemann, Bradley S.; Spiegel, Aldona J. (January 2018). "Risk-Reducing Mastectomy and Breast Reconstruction". Clinics in Plastic Surgery. 45 (1): 129–136. doi:10.1016/j.cps.2017.08.013. PMID   29080654.
  4. ↑ Carbine, Nora E; Lostumbo, Liz; Wallace, Judi; Ko, Henry (2018-04-05). Cochrane Breast Cancer Group (ed.). "Risk-reducing mastectomy for the prevention of primary breast cancer". Cochrane Database of Systematic Reviews. 2019 (1): CD002748. doi:10.1002/14651858.CD002748.pub4. PMC   6494635 . PMID   29620792.
  5. ↑ Steiner, C.A.; Weiss, A. J.; Barrett, M.L.; Fingar, K.R.; Davis, P.H. (2016). "Trends in Bilateral and Unilateral Mastectomies in Hospital Inpatient and Ambulatory Settings, 2005–2013" (PDF). HCUP Statistical Brief (201): 1–14. PMID   27253008 . Retrieved 7 March 2016.
  6. ↑ Zagouri, F.; Chrysikos, D. T.; Sergentanis, T. N.; Giannakopoulou, G.; Zografos, C. G.; Papadimitriou, C. A.; Zografos, G. C. (2013). "Prophylactic mastectomy: An appraisal". The American Surgeon. 79 (2): 205–212. doi: 10.1177/000313481307900233 . PMID   23336662. S2CID   23664548.
  7. ↑ Burke, Erin E.; Portschy, Pamela R.; Tuttle, Todd M. (January 2015). "Prophylactic mastectomy: Who needs it, when and why: Prophylactic Mastectomy". Journal of Surgical Oncology. 111 (1): 91–95. doi:10.1002/jso.23695. PMID   24965368.
  8. 1 2 Scheufler, O.; Fritschen, U. V. (2008). "Prophylaktische Mastektomie bei Frauen mit hohem Brustkrebsrisiko: Indikationen und Alternativen". Handchirurgie · Mikrochirurgie · Plastische Chirurgie. 40 (4): 239–247. doi:10.1055/s-2008-1038774. PMID   18716986.
  9. ↑ Tai, Y. C.; Domchek, S.; Parmigiani, G.; Chen, S. (2007). "Breast Cancer Risk Among Male BRCA1 and BRCA2 Mutation Carriers". JNCI Journal of the National Cancer Institute. 99 (23): 1811–1814. doi:10.1093/jnci/djm203. PMC   2267289 . PMID   18042939.
  10. ↑ "BRCA mutations: cancer risk and genetic testing". National Cancer Institute. January 30, 2018. Retrieved 9 July 2020.
  11. ↑ Jensen, J. A.; Lin, J. H.; Kapoor, N.; Giuliano, A. E. (2012). "Surgical Delay of the Nipple–Areolar Complex: A Powerful Technique to Maximize Nipple Viability Following Nipple-Sparing Mastectomy". Annals of Surgical Oncology. 19 (10): 3171–3176. doi:10.1245/s10434-012-2528-7. PMID   22829005. S2CID   207173683.
  12. 1 2 Metcalfe, K. A.; Semple, J. L.; Narod, S. A. (2004). "Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: A descriptive study". Plastic and Reconstructive Surgery. 114 (2): 360–366. doi:10.1097/01.PRS.0000131877.52740.0E. PMID   15277800.
  13. 1 2 Angelina Jolie (2013-05-14). "My Medical Choice". New York Times . Retrieved 2013-05-15.
  14. ↑ Eliassen AH, Hankinson SE, Rosner B, Holmes MD, Willett WC (October 2010). "Physical activity and risk of breast cancer among postmenopausal women". Arch. Intern. Med. 170 (19): 1758–64. doi:10.1001/archinternmed.2010.363. PMC   3142573 . PMID   20975025.
  15. 1 2 3 4 Nancy Shute (2013-05-14). "Angelina Jolie And The Rise Of Preventive Mastectomy". NPR . Retrieved 14 May 2013.
  16. ↑ "No Guarantees". Newsweek. 2008-08-26. Retrieved 2013-05-14.
  17. ↑ Kannan, Ramya (15 May 2013). "Angelina example may spread prophylactic mastectomy in India". The Hindu. Retrieved 15 May 2013.
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