Breast Health & Cancer: Preventive Breast Surgery
What should I know about risk-reducing mastectomy?
In hopes of avoiding cancer, some high-risk women elect to have both breasts surgically removed, a procedure called “risk-reducing mastectomy.” Sometimes a woman with breast cancer will choose risk- reducing breast surgery on the opposite breast if she is felt to be at increased risk for the development of a new cancer on the other side, or if she is having a mastectomy for treatment of her cancer and desires cosmetic symmetry (evenness).
How much is the risk reduced?
Studies suggest that risk-reducing mastectomy may reduce the risk of breast cancer by at least 90 percent.
What are the challenges of risk-reducing mastectomy?
Breast tissue is mostly made up of fat tissue, connective tissue, and glandular tissue, which produces milk. Breast cancers may develop in the glandular tissue, 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 collar bone to the lower rib margin, and from the middle of the chest, to the mid-axillary line.
In a 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 the most experienced surgeon cannot remove all breast tissue. In order for the skin to survive, some tissue beneath the skin must be left. This is why a small risk of developing breast cancer remains.
Who should have risk-reducing mastectomy surgery?
The decision to have a risk-reducing mastectomy is an individual one. Breast cancer screening in high-risk patients, with digital mammography and breast MRI, is a very effective way of detecting cancers early, and many women choose to be “watched carefully” as opposed to choosing risk-reducing surgery. Medications can also be given to reduce the risk of breast cancer.
Most commonly, risk-reducing mastectomy in the preventive setting is offered to patients who carry gene mutations that create a very high risk of breast cancer (such as BRCA1 and BRCA2, PTEN, TP53, STK11, or CDH1). Risk-reducing mastectomy can also be considered in individuals who have:
- A strong family history of breast cancer.
- a history of lobular carcinoma in situ (LCIS), a benign (non-cancerous) condition that causes increased risk.
- received irradiation to the chest before the age of 30 (such as for treatment of Hodgkin’s lymphoma), which increases the risk of developing breast cancer.
What new surgical options are there for risk-reducing mastectomy?
For women who choose risk-reducing 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. Most of the breast tissue is removed, but most of the skin is spared to hold and shape the reconstructed breast. The nipple and surrounding tissue, called the areola, are removed as well.
When skin-sparing mastectomy is combined with immediate breast reconstruction, the results can be excellent. Women who choose risk-reducing mastectomy, often combined with immediate reconstruction, are very pleased not only with their choice but also with the reconstruction. Nipples can be surgically recreated, or tattooed.
Nipple-sparing mastectomy is another type of skin-sparing procedure that allows a woman to retain her own areola and nipple. During the surgery, the tissue beneath the nipple is examined under the microscope for any atypical cells. If normal, the nipple is kept, but loses sensation. The appearance of the breast after surgery is more similar to the appearance before surgery.
While surgery is not an approach that should be promoted for all high-risk individuals, it can be very important for appropriately selected women.