Is recommending a mastectomy for a BRCA (Breast Cancer Gene) positive patient considered primary prevention?

From the Guidelines

Recommending a mastectomy for a BRCA-positive patient is considered secondary prevention. This preventive measure is taken for individuals who have already been identified as having a high genetic risk (BRCA1 or BRCA2 mutation) but have not yet developed breast cancer. According to the NCCN Guidelines 1, prophylactic mastectomy significantly reduces breast cancer risk by removing the breast tissue before cancer can develop. The evidence supports that risk-reducing mastectomy (RRM) provides a high degree of protection against breast cancer in women carrying a pathogenic BRCA1/2 variant 1.

Key points to consider in this decision include:

• The degree of protection offered by such surgery and the degree of cancer risk should be discussed 1
• Age and life expectancy should be considered during counseling, as should family history 1
• The potential psychosocial effects of RRM, including negative impacts on body image and sexuality, should be addressed 1
• Reconstruction options should also be discussed as part of comprehensive care planning

It's crucial for BRCA-positive patients to understand that while mastectomy substantially decreases cancer risk, it doesn't eliminate it entirely, as some breast tissue may remain 1. The decision should involve genetic counseling and discussion of alternative risk-reduction strategies, such as enhanced surveillance or chemoprevention with tamoxifen.

From the Research

Type of Prevention

Recommending a mastectomy for a BRCA positive patient is considered a form of:

• Primary prevention, as it aims to prevent the occurrence of breast cancer in the first place 2, 3, 4
• Risk-reducing prevention, as it reduces the risk of developing breast cancer in individuals with a high-risk genetic mutation 2, 3, 4

Benefits of Mastectomy

The benefits of mastectomy for BRCA positive patients include:

• Reduced risk of breast cancer, with a decrease in incidence of 90% or more 2, 3, 4
• Potential survival benefit, although this is still being studied and debated 3, 4
• Reduced anxiety and fear of developing breast cancer, which can improve quality of life 2

Considerations and Risks

However, it's also important to consider the potential risks and drawbacks of mastectomy, including:

• Surgical morbidity, such as infection, hematoma, and implant failure 2
• Potential for oncological failure, with a residual risk of breast cancer of around 5% 2
• Body image issues and potential impact on quality of life 2