What Is Prophylactic Mastectomy?
Prophylactic/preventive or risk-reducing mastectomy is a surgery that involves the removal of one or both breasts to lower the risk of breast cancer. A healthcare physician may recommend a preventive mastectomy if one possesses a high risk of developing breast cancer.
The different types of preventive mastectomy are:
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Contralateral Mastectomy - It involves the removal of a healthy breast from someone who has cancer in the other breast.
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Bilateral Mastectomy- Surgical procedure that involves the removal of both breasts.
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Double Mastectomy with breast reconstruction - A surgical procedure that involves the surgical removal of both breasts followed by breast reconstruction using tissues from other parts or implants.
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Nipple Sparing Mastectomy (Subcutaneous Mastectomy)- In this procedure, the breast tissue is removed, but the nipple is left intact, thus giving the appearance of a natural-looking breast.
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Skin-sparing Mastectomy - In this procedure, the areola and nipple are removed, and the breast tissue is removed through a small incision.
A total mastectomy is the one that is most recommended, as it provides the greatest protection against cancer that may develop in any of the remaining breast tissue.
What Are the Indications?
Women who are at higher of developing breast cancer should consider a prophylactic mastectomy.
Women who are at higher risk of developing breast cancer are:
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History of Breast Cancer - women who have a previous history of cancer in one breast have more chance to develop cancer in the other breast and may consider prophylactic mastectomy.
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Familial History - prophylactic mastectomy is a choice for women who have multiple family members (mother, sisters, daughter, or others) with a history of breast cancer or ovarian cancer, especially below the age of fifty years.
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Radiation Therapy - females who have undergone radiation therapy of the chest before 30 years of age are at higher risk of developing breast cancer.
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Lobular Carcinoma in situ - It is an uncommon condition characterized by abnormal cells in the breast tissue (milk glands). It increases the risk of breast cancer.
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Positive Gene Testing Results - women who have positive test results for mutations or changes in certain genes (BRCA1 or BRCA2) that increase the risk of breast cancer development may consider prophylactic mastectomy.
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Dense Breasts or Breast Microcalcification - In some rare cases, prophylactic mastectomy is considered in women with dense breasts or in women with intermediate and diffuse microcalcification (tiny calcium deposits in the breasts). Dense breast tissue makes it difficult to diagnose breast abnormalities and is also linked to an increased risk of breast cancer development.
It is essential that a woman who is considering prophylactic mastectomy talk with the physician about the surgical procedure, the possible complications, and the risk of developing breast cancer (without and with preventive mastectomy).
What Is the Procedure?
Before the procedure, the healthcare provider gives guidelines on how to prepare for the procedure. During the procedure:
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An incision is made in the breast.
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Breast tissue is separated from the skin and chest muscles.
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After breast tissue is removed, breast reconstruction is carried out if it is part of the surgical treatment plan.
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Long tubes may be inserted into the breast to drain the excess fluid.
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Stitches are placed, and the region is covered with a bandage.
The procedure is mostly completed in a few hours and may last longer if reconstruction is also done. Recovery time varies; initial recovery happens in three to four weeks.
How Effective Is the Procedure?
The pros and cons of preventive mastectomy vary depending on one’s risk profile. As per the existing data, preventive mastectomy significantly lowers the risk of breast cancer development in moderate and high-risk women. However, there is no certainty that the procedure will completely protect a woman from breast cancer development. It is almost impossible for a surgeon to remove the whole of the breast tissue, as breast tissue may be distributed widely on the chest wall, rarely in the armpit, above the collarbone, and even far down the abdomen. There is a chance that cancer may develop in the small amount of breast tissue that is left out.
What Are the Possible Drawbacks?
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As with any other surgical procedure, complications like infection, bleeding, and loss of sensation in the breast can occur.
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Prophylactic mastectomy is an irreversible surgical procedure and may have a psychological impact on the women undergoing it. This is because women undergo a change in their body image and a loss of normal breast functions. The common psychological effects include feelings about body image, sexual relationships, and feminity. The loss of nipple due to total mastectomy may hinder sexual arousal. Therefore, women must discuss the procedure, the possible complications, and alternative options with the healthcare provider before undergoing the procedure.
What Are the Alternative Options for Women at Increased Risk but Not Highest Risk?
In women who are not at the highest risk for breast cancer (those who do not have mutations in breast cancer-linked genes or do not have a clinical/medical history that increases risk), risk-reducing surgeries are not considered an appropriate cancer preventive option. Risk assessment models like BCRAT (breast cancer risk assessment tool) are used to estimate breast cancer risk for the coming five years and estimate lifetime risk. Those with a five-year risk of 1.67 percent or greater are at a higher than average risk for breast cancer development.
Certain medications are shown to reduce the risk of breast cancer. In women with a high-risk profile, as per BCRAT, medications like raloxifene and tamoxifen are Food and Drug Administration (FDA) approved for reducing breast cancer risk. Raloxifene is used in postmenopausal women, while tamoxifen is used in pre- and postmenopausal women.
Exemestane, which is an aromatase inhibitor, is another drug used to reduce breast cancer risk.
In some women who have undergone breast surgery, drugs are used as adjuvant therapy to reduce cancer risk. These drugs include chemotherapy agents, aromatase inhibitors, Tamoxifen, and Trastuzumab.
Conclusion
Bilateral preventive mastectomy has been found to lower breast cancer risk by 95 percent in females who have deleterious mutations in the BRAC1 and BRAC2 genes and by about 90 percent in women with a strong familial history of breast cancer. Even with a total mastectomy, it is impossible to remove the entire breast tissue that poses a risk of becoming cancerous. The decision for surgery is taken under the physician's guidance, considering one’s unique risk factors.
