Risk - Reducing Surgery

 

What kinds of surgery can reduce the risk of breast cancer?

Two kinds of surgery can be performed to reduce the risk of breast cancer in a woman who has never been diagnosed with breast cancer but is known to be at very high risk of the disease.

A woman can be at very high risk of developing breast cancer if she has a strong family history of breast and/or ovarian cancer, a deleterious (disease-causing) mutation in the BRCA1 gene or the BRCA2 gene, or a high-penetrance mutation in one of several other genes associated with breast cancer risk, such as TP53 or PTEN

The most common risk-reducing surgery is bilateral prophylactic mastectomy (also called bilateral risk-reducing mastectomy). Bilateral prophylactic mastectomy may involve complete removal of both breasts, including the nipples, or it may involve removal of as much breast tissue as possible while leaving the nipples intact (subcutaneous or nipple-sparing mastectomy). Subcutaneous mastectomies preserve the nipple and allow for more natural-looking breasts if a woman chooses to have breast reconstruction surgery afterward. 

How effective are risk-reducing surgeries?

Bilateral prophylactic mastectomy has been shown to reduce the risk of breast cancer by at least 95 percent in women who have a deleterious (disease-causing) mutation in the BRCA1 gene or the BRCA2 gene and by up to 90 percent in women who have a strong family history of breast cancer

Which women might consider having surgery to reduce their risk of breast cancer?

Women who inherit a deleterious mutation in the BRCA1 gene or the BRCA2 gene or mutations in certain other genes that greatly increase the risk of developing breast cancer may consider having bilateral prophylactic mastectomy and/or bilateral prophylactic salpingo-oopherectomy to reduce this risk.

Other women who are at very high risk of breast cancer may also consider bilateral prophylactic mastectomy, including:

  • those with a strong family history of breast cancer (such as having a mother, sister, and/or daughter who was diagnosed with bilateral breast cancer or with breast cancer before age 50 years or having multiple family members with breast or ovarian cancer)
  • those with lobular carcinoma insitu (LCIS) plus a family history of breast cancer (LCIS is a condition in which abnormal cells are found in the lobules of the breast. It is not cancer, but women with LCIS have an increased risk of developing invasive breast cancer in either breast. Many breast surgeons consider prophylactic mastectomy to be an overly aggressive approach for women with LCIS who do not have a strong family history or other risk factors.)
  • those who have had previous radiation therapy to the chest (including the breasts) before the age of 30 years—for example, if they were treated with radiation therapy for Hodgkins lymphoma [Such women are at high risk of developing breast cancer throughout their lives.

Can a woman have risk-reducing surgery if she has already been diagnosed with breast cancer?  

Yes. Some women who have been diagnosed with cancer in one breast, particularly those who are known to be at very high risk, may consider having the other breast (called the contralateral breast) removed as well, even if there is no sign of cancer in that breast. Prophylactic surgery to remove a contralateral breast during breast cancer surgery (known as contralateral prophylactic mastectomy) reduces the risk of breast cancer in that breast, although it is not yet known whether this risk reduction translates into longer survival for the patient.

However, doctors often discourage contralateral prophylactic mastectomy for women with cancer in one breast who do not meet the criteria of being at very high risk of developing a contralateral breast cancer. For such women, the risk of developing another breast cancer, either in the same or the contralateral breast, is very small, especially if they receive adjuvant chemotherapy or hormone therapy as part of their cancer treatment.

Given that most women with breast cancer have a low risk of developing the disease in their contralateral breast, women who are not known to be at very high risk but who remain concerned about cancer development in their other breast may want to consider options other than surgery to further reduce their risk of a contralateral breast cancer.

What are the potential harms of risk-reducing surgeries?

As with any other major surgery, bilateral prophylactic mastectomy and bilateral prophylactic salpingo-oopherectomy have potential complications or harms, such as bleeding or infection. Also, both surgeries are irreversible. 

Bilateral prophylactic mastectomy can also affect a woman’s psychological well-being due to a change in body image and the loss of normal breast functions. Although most women who choose to have this surgery are satisfied with their decision, they can still experience anxiety and concerns about body image. The most common psychological side effects include difficulties with body appearance, with feelings of femininity, and with sexual relationships. Women who undergo total mastectomies lose nipple sensation, which may hinder sexual arousal.

Bilateral prophylactic salpingo-oophorectomy causes a sudden drop in estrogen production, which will induce early menopause in a premenopausal woman. Surgical menopause can cause an abrupt onset of menopausal symptoms, including hot flashes, insomnia, anxiety, and depression, and some of these symptoms can be severe. The long-term effects of surgical menopause include decreased sex drive, vaginal dryness, and decreased bone density.

What can women at very high risk do if they do not want to undergo risk-reducing surgery? 

Some women who are at very high risk of breast cancer (or of contralateral breast cancer) may undergo more frequent breast cancer screening (also called enhanced screening). For example, they may have yearly mammograms and yearly MRI screening—with these tests staggered so that the breasts are imaged every 6 months—as well as clinical breast examinations performed regularly by a health care professional. Enhanced screening may increase the chance of detecting breast cancer at an early stage, when it may have a better chance of being treated successfully.

 

  • University of Cape Town
  • King Edward VII's Hospital
  • Royal Australasian College of Surgeons
  • Royal Hospital for Women
  • prime wales hospital
  • BreastScreen Australia