More Women Undergoing Preventive Mastectomies


Its a pretty safe bet that the threat of breast cancer crosses the minds of most American women sometime in their lives. Simply being a woman creates a risk factor, says the American Cancer Society; womens breast cells are constantly exposed to the growth-promoting effects of estrogen and progesterone.

But what if you fall into the 5% to 10% group of breast cancer cases thought to be hereditary and often caused by gene mutations inherited from your parents families?

Women whose mother, sister, daughter, or two or more close relatives has a history of breast cancer, diagnosed before age 50, are at a higher risk of being diagnosed with breast cancer, but thanks to advances in medical science, there are steps they can take to lower their risk, including increased surveillance, mammograms and more frequent MRI and ultrasounds.

More radical interventions like preventive mastectomy are responses to two distinct scenarios:

Bilateral prophylactic mastectomy helps women who are at high risk because of hereditary factors like high family incidence or the mutation in the BRCA1 or BRCA2 gene.

Contralateral prophylactic mastectomy (CPM) references surgery on women who have received a diagnosis of unilateral breast cancer or cancer in one breast and elect to have their unaffected breast removed as a preventative measure.

High-risk gene intervention

A mutated copy of either the BRCA1 or BRCA2 gene from a parent portends a high risk of developing breast canceras high as 80% for some families, according to experts. These cancers tend to occur in younger women, more often affect both breasts and present with a risk of ovarian cancer.

The rate of increase in these surgeries among women with the BRCA gene mutation has increased somewhat over recent years, says Dr. Todd Tuttle, chief of surgical oncology at the University of Minnesota.

And theres compelling evidence for women with a mutated copy of either gene to undergo a mastectomy: a 90% to 95% chance of reducing the risk for getting breast and ovarian cancer, experts say. For added insurance, some women go on to have an oophorectomy, removal of the ovaries, and also sometimes the fallopian tubes.

The prophylactic mastectomy and removal of ovaries create a double whammy for a woman, says Dr. Marisa Weiss, president and founder of and director of breast health and breast radiation oncology at Lankenau Medical Center. The oophorectomy has significant side effects like early menopause, and can cause a lot of symptoms that impact self image and sexual function when women already have to work hard to enjoy sex.

Still, Weiss is a proponent of the measures in the right circumstance. Along with BRCA mutation zeroes in on family history which, she says, trumps genes. We might not have identified a specific gene yet.

Dr. Monica Morrow, chief of Breast Service at Memorial Sloane-Kettering Cancer Center adds, prophylactic mastectomy combined with oophorectomy are perfectly sensible options for women with BRCA gene mutations, particularly those with BRCA1 issues.

The same cannot be said for CPM, yet ironically the surgery has increased dramatically over recent years, says Tuttle, whose views were seconded by other experts. Realistically, the likelihood of cancer spreading from the affected breast to the other breast is extremely low--about 2% to 5% for a 40-year-old woman in a 10-year period, according Morrow who worked with colleagues to evaluate 2,965 women with stage zero to three primary unilateral breast cancer.

Within a year of treatment for their index cancer, 13.8% of the women elected CPM, with rates increasing from 6.7% in 1997 to 24.2% in 2005. Only 57 (13%) of these 407 women were actually at an increased risk for a second breast cancer based on BRCA or family history, Morrow says.

Yet experts say CPM does nothing to change the diagnosis: A woman is more likely to die of the metastasis of the original cancer to the bone or another organ like the brain, liver or lung than facing the likelihood of the original cancer spreading to the unaffected breast.

Minus BRCA1 or BRCA2, there is no evidence that CPM saves lives, says Dr. George Sledge, Jr., coleader of the breast cancer program at Indiana University Simon Cancer Center and president of the American Society of Clinical Oncology.

Fear more than risk

Sledge says that mammography alternated with MRI can help physicians monitor even fairly- aggressive cancers. I dont want to suggest that these are simple decisions for women, but [in the case of an index cancer in one breast] there are other options to the preventive surgery.

Morrow says physicians are just beginning to study why large numbers of women--particularly young, educated white women--choose CPM following a diagnosis of unilateral breast cancer.

Anxiety about breast cancer is a strong predictor of whether a woman elects to have the surgery, researchers at University of Michigan say.

Experts agree that physicians must do a better job providing patients with accurate information from the start. For example, women need to know their risk of cancer increases with age. "Your grandmother getting breast cancer at 65 or 70," says Morrow, doesnt warrant you running out to test for the BRCA gene.

Patients are often relying on the Internet and the media and hear and read only the scariest stories.

Meanwhile, many of us spend considerable time trying to explain to unilateral breast cancer patients their chances of getting cancer in the second breast are low, says Morrow. I dont care. I want it anyway. I am a mother of young kids, they answer.

Tuttle suggests another factor driving what he calls the mastectomy craze is that techniques are so much better than they were 10 or 15 years ago. Mastectomies spare skin and the nipple, and cosmetic outcomes can be quite good.

While most women are satisfied with reconstruction, the whole procedure can have other repercussions. Weiss says there can be loss of sensation in the breast area and discomfort which can cause changes in a relationship. Its not just the absence of one [breast] and the presence of another.

Nonetheless, mastectomies are safe, but they are also irreversible. And they are big surgeries. Mastectomy with reconstruction is a five-hour operation, a bit of a hospital stay and a good months recovery.

And, says Tuttle, while reconstruction restores self image and fulfills the objective for breast symmetry, it is a huge commitmentespecially for those who dont have cancer.