What is the indication for a prophylactic (preventive) mastectomy?

From the Guidelines

A prophylactic mastectomy is done to significantly reduce the risk of breast cancer in high-risk individuals, with studies showing it can decrease the risk by 90-95%. This procedure is typically considered for individuals with a strong genetic predisposition to breast cancer, such as those with BRCA1 or BRCA2 gene mutations, as well as those with a significant family history of breast cancer or previous radiation therapy to the chest before age 30 1. The decision to undergo a prophylactic mastectomy should be made on a case-by-case basis, taking into account the individual's risk factors, age, life expectancy, and family history, as well as the potential psychosocial effects of the surgery 1.

Some key points to consider when discussing prophylactic mastectomy with patients include:

• The degree of protection offered by the surgery, with meta-analyses showing that bilateral total mastectomy can reduce the risk of breast cancer and even decrease mortality 1
• The potential impact on body image and sexuality, with some studies showing negative effects, but also reported decreases in worry about breast cancer 1
• The importance of thorough counseling and discussion with healthcare providers, genetic counselors, and possibly mental health professionals to ensure the patient fully understands the benefits, limitations, and alternatives to surgery
• The different types of prophylactic mastectomies available, including total mastectomy and nipple-sparing procedures, and the potential for reconstruction options.

It is essential to weigh the potential benefits of prophylactic mastectomy against the potential risks and psychosocial effects, and to make an informed decision based on individual circumstances and the most recent and highest-quality evidence available 1.

From the Research

Reasons for Prophylactic Mastectomy

• The primary reason for performing a prophylactic mastectomy is to reduce the risk of developing breast cancer in women who are at high risk due to genetic mutations, such as BRCA1 and BRCA2 2, 3.
• Women with a family history of breast cancer or those who have tested positive for BRCA1 or BRCA2 gene mutations are considered to be at high risk and may benefit from prophylactic mastectomy 2, 3, 4.
• Prophylactic mastectomy can reduce the risk of breast cancer by 90% or more in patients with BRCA mutations 2, 3, 5, 6.

Benefits and Risks

• The benefits of prophylactic mastectomy include a significant reduction in the risk of developing breast cancer and a possible improvement in life expectancy 2, 3, 6.
• However, prophylactic mastectomy also carries risks, such as surgical morbidity, including ischemia of the skin and/or areola-nipple complex, hematomas, infections, implant failure, and partial or total autologous flap loss 2, 5.
• Additionally, prophylactic mastectomy can result in sequelae, such as loss of sensitivity of the areola-nipple complex, possible paresthesias, painful sensations, and the need for re-adaptation to a different body image 2, 4.

Surgical Techniques and Options

• Prophylactic mastectomy can be performed using different surgical techniques, including nipple-sparing mastectomy, which is considered the gold standard due to its ability to optimize oncological and aesthetic results 2.
• Nipple-sparing mastectomy involves the preservation of the skin envelope and the nipple-areola complex, providing superior cosmetic results 2.
• Breast reconstruction is also an option for women who undergo prophylactic mastectomy, and can be performed immediately or at a later time 2, 5.