Prophylactic Mastectomy: Reducing the Risk of Breast Cancer

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Plastic Surgeon and Breast Reconstruction Specialist Dr. Constance Chen Offers Practical Tips

Dr. Constance Chen

After carefully considering their options, some high-risk women make the difficult decision to remove both breasts before a breast cancer diagnosis in order to reduce their odds of developing breast cancer later. This choice has become more common as breast reconstruction options have improved.

Every woman is at risk for breast cancer just by being female and growing older. Many women are diligently attentive to the lifestyle factors that can reduce their risk: They don't smoke, eat a plant-based diet, control their weight, exercise regularly, avoid hormone therapy, and limit exposure to radiation and environmental pollution. For some high-risk women, however, these measures may not be enough.

“As we've learned more about the genetic factors that contribute to breast cancer, we've been better able to identify women who are at particularly high risk,” says plastic surgeon and breast reconstruction specialist Dr. Constance M. Chen. “Women with genetic mutations or strong family history of breast cancer know that they have a lifetime risk that can be upwards of 85%. Many have watched multiple family members struggle through treatment and die from breast cancer, or they have done intense amounts of research and spoken to a genetic counselor. After carefully considering their options, some high-risk women make the difficult decision to remove both breasts before a breast cancer diagnosis in order to reduce their odds of developing breast cancer later. This choice has become more common as breast reconstruction options have improved.”

In the 1990s, scientists discovered specific genetic mutations that significantly increase the risk of breast cancer. The best known are the BRCA1 and BRCA2 mutations, tumor suppressor genes that cause cells to become more vulnerable to changing in ways that can lead to cancer. While about 12 percent of women in the general population develop breast cancer over the course of their lives, among women who inherit the BRCA1 and BRCA2 mutations, as many as 85% or more will develop breast cancer by the age of 70 years. Bilateral prophylactic mastectomy – preventive removal of both breasts – reduces the risk of breast cancer in women with harmful BRCA1 and BRCA2 mutations by 95%. As tests for genetic mutations have become widespread, the number of prophylactic mastectomies has increased dramatically.

BRCA1 and BRCA2 mutations account for about one-quarter of hereditary breast cancers. Even with a negative BRCA1 and BRCA2 test, there are other factors that put women at higher risk:
Strong family history: Having a first-degree relative (mother, sister, or daughter) diagnosed with breast cancer before the age of 50 or with bilateral breast cancer or having multiple family members with breast or ovarian cancer.

Personal history: Having cancer in one breast may increase the risk for the other breast, particularly if there is a family history or the presence of other risk factors such as lobular carcinoma in situ (LCIS) a non-invasive condition that is a marker for increased risk.

Radiation therapy to the trunk before the age of 30 increases the risk of breast cancer throughout a woman's life.

“Learning that she is at high risk for breast cancer, whether as a result of a genetic test or any other factor, presents a woman with difficult decisions,” says. Dr. Chen. “She must weigh all the available information, including her options for reconstruction. New advances in breast reconstruction have made the choice a little easier, since it is possible to recreate soft, warm, living breasts using a patient’s own tissue.”

The “gold standard” in breast reconstruction is natural tissue breast reconstruction, which uses a woman's own tissue to fashion a new breast that reacts like any other part of her body, growing or shrinking as she gains or loses weight, for example. “Autologous tissue breast reconstruction has been done for decades,” says Dr. Chen, “but microsurgical techniques make it unnecessary to sacrifice muscle from the donor site, usually the abdomen, to create the new breast. Preserving muscle enables faster recovery and means a woman can maintain muscle strength over the long term, and it is even possible to reconnect the nerves to restore sensation. With careful planning, it is also possible to preserve the skin and the nipple-areola complex at the time of mastectomy to produce a superior aesthetic result.”

“Every woman at high risk for breast cancer has different personal and medical considerations that inform her decisions,” says Dr. Chen. “While most women who have chosen to undergo prophylactic mastectomy are glad they did it and feel a sense of relief, it isn't right for everyone. When she takes the time to consider all the factors and all the available information, every woman will make the decision that is right for her.”

Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. http://www.constancechenmd.com

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Melissa Chefec
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