Preventive Mastectomy

   One out of every eight women in the United States will experience breast cancer in her lifetime. Although most of these women will be long term survivors, more than 40,000 women in the United States died from breast cancer last year. The diagnosis is at best, frightening for most women and their families. The chance of breast cancer is even greater for women who have certain high risk factors. Some of these high risk patients may consider a 'preventive' mastectomy. 
   A preventive mastectomy, also called a prophylactic or risk-reducing mastectomy, is defined as the surgical removal of one or both breasts in an effort to lower the risk of breast cancer. There are two types of preventive mastectomy: A 'total' mastectomy removes the entire breast and nipple and a'subcutaneous' mastectomy which removes the breast tissue, but preserves the nipple. Many physicians recommend a total mastectomy because more breast tissue is removed, although recent techniques have increased the use of 'nipple sparing' mastectomies. Current data has shown that preventive mastectomy reduces the risk of breast cancer by approximately 90% in women who are at elevated risk of developing the disease. It is, however, not a guarantee. In a study conducted at the Mayo Clinic, three of 214 women who underwent preventive mastectomy developed breast cancer over a 14-year period. As those numbers indicate there is still a small chance a woman could develop breast cancer since breast tissue on the chest wall and in surrounding areas usually remains even after a mastectomy.   
   There are several factors which increase the risk of breast cancer:

A personal history of breast cancer in one breast: A woman who has cancer in one breast is more likely to develop cancer in her other breast. If a woman has chosen to have a mastectomy on one side, she may consider mastectomy on the 'healthy' breast at the same time to reduce her chances of developing cancer. This is particularly true for women who have chosen to have a mastectomy with reconstruction. 

Strong family history of breast cancer: A woman is at particular risk if her mother, sister or daughter has had breast cancer, especially if they were diagnosed earlier than 50 years of age. A woman with a family history of breast and ovarian cancer is also at increased risk for breast cancer.

Genetic 'mutations': Certain genes have been discovered, that when altered can increase the risk of breast cancer. The most common breast cancer genetic mutations (BRCA1 and BRCA2) account for 5-10% of all breast cancers in the United States and any woman who carries the abnormal gene has an 80 to 90% chance of developing breast (and other) cancers. The altered gene can be present in the father or the mother, and passed on to statistically, half of the children in a family.  
High risk pathology on breast biopsy: Occasionally, a breast biopsy, although benign or non-cancerous, may confirm an increased risk of breast cancer. 

Previous history of radiation to the chest wall: Women who have received radiation therapy to the chest early in life (such as for Hodgkin's Lymphoma), have an increased risk of developing breast cancer.
  

   Preventive or prophylactic mastectomy is still widely debated in the medical community. Some physicians do not believe it is appropriate to remove a woman's breast unless she has developed cancer. There are many good alternatives to preventive mastectomy for women at high risk. These include very closer surveillance with periodic mammograms or other breast imaging studies (such as ultrasound or MRI scan) and more frequent breast exams by a physician or other health care professional. There are also medications that can be used by some women to reduce the risk of breast cancer. These medications (Tamoxifen or Evista), have been shown to reduce the risk of developing breast cancer by as much as 50%. Despite these other alternatives the majority of surgical oncologists (surgeons specializing in the treatment of cancer), believe that a preventive mastectomy is beneficial and appropriate for selected women who are at very high risk of breast cancer, and justifiably concerned about developing the disease. Recent data has shown that in women diagnosed with breast cancer in one breast, the choice for removal of the opposite or 'healthy' breast has more than doubled in the United States during the last six years. If the risk of developing breast cancer is high enough, preventive mastectomy is not only justified, but well reasoned.
   The choice for a preventive mastectomy, however, should only be made after a thorough discussion of alternative approaches and a detailed review of the operation, potential benefits and risks. Studies have shown that while women are generally satisfied with their decision for preventive mastectomy, more time should be devoted to discussion with these women before their surgery. If you or someone you know is considering prophylactic mastectomy, make certain they receive the necessary information from a surgeon specializing in breast disease. 

Breast Reconstruction for Prophylactic Mastectomy

by Frederick G. Weniger

   Mastectomy patients can be left with physical defects that can be difficult to accept. In fact, it is known that mastectomy can lead to psychological problems such as depression, loss of sexual interest, a negative body image and loss of femininity, increased fear of cancer recurrence, and self-consciousness even in clothing. Breast reconstruction lessens these emotional burdens and allows the patient to focus on her success and her recovery.
   Breast reconstruction is currently considered to be an integral part of prophylactic mastectomy. After decades of development of new techniques, we now enjoy multiple options for breast reconstruction. In general, breasts can be reconstructed with breast implants or with tissues of a woman's body moved from other areas to create the new likeness of a breast. These procedures are often done immediately after the mastectomy is completed on the operating table, so that the woman awakens with her breast reconstruction procedure completed, not ever having to cope with the frank absence of her breast.
   For most women, the best reconstructive option is a breast implant. Although this was the very first reconstructive option available approximately 30 years ago, technology has developed to make this a very attractive option for most patients. Implant reconstructions are relatively fast, safe operations that add little extra recovery to the mastectomy operation. These operations can even be done in an outpatient setting. Both saline and silicone breast implants are available for this purpose. Currently, many implant reconstructions are done in stages, with the immediate operation consisting of placing a tissue expander prosthesis. This device, which is shaped like a breast implant, is then gradually filled in the plastic surgeon's office over the following two months in order to slowly stretch out the skin. Eventually, the expander is removed and the permanent breast implant is placed into the stretched "pocket" of skin and muscle, thus more reliably delivering a soft, natural appearing breast. Breast implant reconstructions are especially good in prophylactic mastectomy patients because they provide a relatively easy method to achieve symmetrical, natural results without the need for extensive surgery.
   In contrast, other patients will elect to have an "autologous tissue" reconstruction, made of their own excess tissues taken from other areas. Most commonly, the excess skin and fat is taken from the abdomen, similar to an abdominoplasty. This operation is called a Transverse Rectus Abdominus Myocutaneous Flap (TRAM Flap). Another option is to take skin and fat from the back and create a new breast mound out of this tissue. As one might expect, there is often not much bulk from this area compared to the abdomen. For this reason, a breast implant is often added underneath this new breast to give more volume. This procedure is a Latissimus Dorsi Myocutaneous Flap. Other real tissue procedures exist as well. Although these techniques avoid some of the issues related to the use of implants, they generally are larger procedures than implant reconstructions, and require a more difficult recovery period.
   Usually after mastectomies for breast cancer, new nipples and areolas must be reconstructed on the new breast mounds to complete the appearance of the breasts. This is because the nipples and areolas must be removed in most breast cancer scenarios because these structures contain duct tissue which may contain cancer cells. In contrast, many prophylactic mastectomies may preserve the nipple-areolar complexes which further improves the cosmetic outcome of the breast reconstruction. In such cases, scars from the mastectomies can be hidden in the crease under the breast, so that the final result can look just like the original breasts (since only the contents and not the covering of the breasts has been altered).
   The best option for an individual patient is a decision based on discussions between the patient and the plastic surgeon, and must include dialogue from the breast cancer surgeon. In the end, the decision for a certain type of reconstruction must be a conclusion individualized to the patient's aesthetic desires and her particular medical circumstances.
   Certainly the decision to have a prophylactic mastectomy is not an easy one. Fortunately, many options exist to reconstruct the breasts afterward with very nice aesthetic results. Therefore, the choice to proceed with prophylactic mastectomy can be based more on the medical benefits of the mastectomy than on cosmetic concerns.
Join in a discussion with leading Breast Disease and Breast Reconstruction experts, Dr. Virginia Herrmann and Dr. Frederick Weniger on Wednesday, October 29 at the Hilton Oceanfront Resort. This event is part of the Live Smart series offered by Pink Magazine and The Bedminster Group. This evening is free and open to the public.