Is bilateral prophylactic mastectomy indicated for atypical ductal or lobular hyperplasia (ADH or ALH)?

From the Guidelines

Bilateral prophylactic mastectomy is generally not routinely indicated for atypical hyperplasia alone. For most women with atypical hyperplasia (either atypical ductal hyperplasia or atypical lobular hyperplasia), close surveillance with regular clinical breast exams and imaging is the standard approach, rather than surgical removal of both breasts. Management typically includes annual mammography, often with supplemental MRI screening, and regular clinical examinations every 6-12 months. Risk-reducing medications such as tamoxifen (20mg daily for 5 years), raloxifene, or aromatase inhibitors may be considered as these can reduce breast cancer risk by approximately 50-65% in women with atypical hyperplasia 1.

Some key points to consider in the management of atypical hyperplasia include:

• The increased risk of breast cancer associated with atypical hyperplasia, which is approximately 4-5 fold higher than the general population 1
• The role of risk-reducing medications in reducing breast cancer risk in women with atypical hyperplasia 1
• The importance of individualized decision-making, taking into account the patient's personal preferences, family history, and other risk factors 1
• The potential psychosocial effects of prophylactic mastectomy, including negative impacts on body image and sexuality, which should be addressed through counseling 1

Prophylactic mastectomy might be considered in specific circumstances, such as when atypical hyperplasia occurs in combination with other significant risk factors like strong family history, known genetic mutations (BRCA1/2), or personal preference after thorough risk counseling. The decision should be individualized, as atypical hyperplasia increases breast cancer risk approximately 4-5 fold but most women with this finding will never develop breast cancer, making extensive surgery excessive for many patients. According to the most recent guidelines, the NCCN Guidelines Panel supports discussion of the option of RRM for women on a case-by-case basis 1.

From the Research

Indications for Bilateral Prophylactic Mastectomy

• Bilateral prophylactic mastectomy is generally considered for women with high-risk breast cancer factors, including atypical hyperplasia, family history of breast cancer, or previous breast biopsies with benign findings 2.
• The procedure is most commonly recommended for women with BRCA1 or BRCA2 gene mutations, who have a significantly increased risk of developing breast cancer 3.
• For women with atypical hyperplasia, the decision to undergo bilateral prophylactic mastectomy should be made on a case-by-case basis, taking into account individual risk factors and preferences 4.

Efficacy of Bilateral Prophylactic Mastectomy

• Studies have shown that bilateral prophylactic mastectomy can reduce the risk of developing breast cancer by 90% or more in high-risk women 2, 3.
• However, the absolute risk of breast cancer incidence and death in women who do not undergo the procedure may be relatively low 2.
• The efficacy of bilateral prophylactic mastectomy in reducing breast cancer risk is well established, but the decision to undergo the procedure should be based on individual circumstances and risk factors 5, 4.

Considerations and Alternatives

• Women with atypical hyperplasia should be counseled on risk-reducing strategies, including preventive endocrine therapy, enhanced surveillance imaging, and lifestyle modifications 6.
• Bilateral prophylactic mastectomy is not the only option for reducing breast cancer risk, and alternative strategies such as chemoprevention and risk-reducing salpingo-oophorectomy should be considered 3.
• The decision to undergo bilateral prophylactic mastectomy should be made after careful consideration of the potential benefits and risks, including surgical morbidity and potential sequelae 3.