From the Guidelines
Prophylactic mastectomy is most suitable for women with BRCA1 or BRCA2 gene mutations, as it significantly reduces the risk of breast cancer by 90-95%. This preventive surgery is generally recommended for women with a high lifetime risk of breast cancer, such as those with BRCA1 or BRCA2 gene mutations, which increase lifetime breast cancer risk to 45-72% 1. It's also appropriate for those with strong family histories of breast cancer, previous radiation therapy to the chest before age 30, or certain genetic conditions like Li-Fraumeni or Cowden syndrome. Women who have already had cancer in one breast may consider prophylactic removal of the other breast, especially if they have additional risk factors. The procedure typically involves either total mastectomy (removing all breast tissue) or nipple-sparing mastectomy, often with reconstruction options.
Some key points to consider when deciding on prophylactic mastectomy include:
- The risk of breast cancer remains increased with age in carriers of a BRCA1/2 pathogenic or likely pathogenic variant, so age and life expectancy should be considered during counseling 1
- The potential psychosocial effects of prophylactic mastectomy, including negative impacts on body image and sexuality, should be addressed 1
- The decision should be made after genetic counseling, risk assessment, and thorough discussion with healthcare providers about alternatives like enhanced screening or chemoprevention with medications like tamoxifen or raloxifene 1
- While prophylactic mastectomy significantly reduces breast cancer risk, it doesn't eliminate it entirely, as some breast tissue always remains, and this major, irreversible surgery carries physical and psychological implications, making careful consideration essential 1
It's worth noting that the most recent and highest quality study, published in 2021, supports the discussion of the option of risk-reducing mastectomy (RRM) for women on a case-by-case basis, and counseling regarding the degree of protection offered by such surgery and the degree of cancer risk should be provided 1.
From the Research
Prophylactic Mastectomy Suitability
Prophylactic mastectomy is a surgical procedure that involves the removal of one or both breasts to prevent breast cancer. The suitability of this procedure depends on various factors, including:
- Personal and family history of breast cancer
- Presence of pathogenic variants in high-risk genes, such as BRCA1 and BRCA2
- Risk assessment based on genetic testing and other factors
Indications for Prophylactic Mastectomy
The following are indications for prophylactic mastectomy:
- Strong family history of breast cancer 2
- Prior history of breast cancer 2
- Histological risk factors, such as atypical ductal hyperplasia or lobular carcinoma in situ 2
- Presence of a BRCA1 or BRCA2 mutation 3, 4, 5
Benefits and Risks of Prophylactic Mastectomy
The benefits of prophylactic mastectomy include:
- Reduction in the risk of breast cancer by 90% or more 3, 4, 5
- Improved quality of life and reduced anxiety about developing breast cancer 3, 4 The risks and complications of prophylactic mastectomy include:
- Surgical morbidity, such as infection, hematoma, and implant failure 4
- Loss of sensitivity in the nipple-areola complex and possible paresthesias 4
- Body image issues and dissatisfaction with scars 4
Surgical Techniques and Reconstruction Options
Prophylactic mastectomy can be performed using various surgical techniques, including:
- Nipple-sparing mastectomy, which preserves the skin envelope and nipple-areola complex 4
- Skin-sparing mastectomy, which preserves the skin envelope but not the nipple-areola complex Reconstruction options after prophylactic mastectomy include:
- Immediate reconstruction with implants or autologous tissue 3, 4
- Delayed reconstruction after the initial surgery 4