Prophylactic Mastectomy: Reducing Your Risk of Breast Cancer

Breast cancer is a risk for all people, but several different factors can put you at a higher risk of developing it in your lifetime.

About 5 to 10 percent of breast cancer cases come from gene mutations, according to the American Cancer Society. The most common gene mutations in hereditary breast cancer come in the BRCA1 and BRCA2 genes.

Healthy BRCA genes can help keep cancer cells from growing. But when there’s a mutation, the risk of breast, ovarian, and other types of cancer rises.

Mona Janfaza, MD, says a BRCA1 or BRCA2 gene mutation can increase your risk of developing breast cancer in your lifetime by 60 to 80 percent.

“It’s a very, very high risk,” says Dr. Janfaza, an attending breast surgeon with Bayview Breast Care at UPMC Hamot. “And the type of breast cancer, if they do get it, is a more aggressive, less favorable type of breast cancer.”

While the gene mutation doesn’t guarantee breast cancer, patients with the mutation are at higher risk. Doctors watch those patients closely and offer them options to reduce their risk of cancer.

One option for patients who are found to have a BRCA gene mutation is a prophylactic mastectomy. The procedure is aimed to reduce your risk of developing breast cancer.

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Who Is a Candidate for Prophylactic Mastectomy?

People with a personal history of cancer or strong family history of breast, ovarian, or related cancers may undergo genetic counseling and genetic testing. The procedures can determine if they have a mutation that causes a higher risk.

BRCA gene mutations cause the most cases of hereditary breast cancers, but genetic counselors will look at other genes. Mutations in the PTEN and TP53 genes also can cause a higher risk of breast cancer.

If the test comes back positive for a mutation, the patients will meet with a surgeon who will discuss their potential options:

  • Heightened surveillance: Here, a mastectomy is not performed at the time. Instead, a high-risk team will keep tabs on you. The process includes:
    • Breast self-awareness beginning at 18 years old
    • Clinical breast exams every 6-12 months, beginning at age 25
    • Annual MRI, beginning at age 25
    • Annual mammograms beginning at age 30
    • Risk-reducing medicines, such as tamoxifen
  • Risk-reducing mastectomy: This procedure removes breast tissue and potentially more.

Dr. Janfaza says the surgical team will thoroughly talk through the options, providing the risks and benefits of both treatments. A mastectomy is a treatment for some patients who have breast cancer. A risk-reducing mastectomy is a potentially preventive surgery to reduce your future risk. Some patients might be unsure about getting one – it’s a personal decision.

“A lot goes into these patients choosing to get this risk-reducing mastectomy,” Dr. Janfaza says. “Mentally, emotionally, their reconstructive options. It’s a pretty massive thing for them to undertake. Ultimately, we’re doing this to save their lives.”

Types of Prophylactic Mastectomies

There are three main types of risk-reducing mastectomies:

  • Total mastectomy: This procedure removes the nipple and areola, and the breast tissue is removed through that incision.
  • Skin-sparing mastectomy: The skin of the nipple and areola is removed, and the breast tissue is removed through that small incision.
  • Nipple-sparing mastectomy: The surgeon removes only breast tissue, leaving the nipple and areola alone.

Breast reconstruction after mastectomy

After getting a risk-reducing mastectomy, patients can choose whether they want reconstructive breast surgery.

If a patient chooses to get reconstruction, surgeons either can use implants or transfer tissue from another spot on the patient’s body.

If a patient chooses not to get reconstruction, surgeons remove the nipple and any excess skin during the mastectomy, leaving a smooth, flattened chest.

Recovery from risk-reducing mastectomy

A patient’s recovery from a risk-reducing mastectomy depends on the patient and whether reconstruction is performed.

In most cases, recovery from a mastectomy without reconstruction takes around six weeks, Dr. Janfaza says. With reconstruction, recovery can last 12 weeks or longer, depending on the type of reconstruction performed.

Benefits and Risks of Prophylactic Mastectomy

There are several ways a risk-reducing mastectomy can benefit a patient who is at high risk of breast cancer.

The biggest benefit comes with a drastically reduced risk of breast cancer. A prophylactic mastectomy can’t eliminate a person’s chance of getting breast cancer. That’s because impossible to remove every cell of breast tissue.

However, Dr. Janfaza says, the procedure can reduce the risk of breast cancer by 90 percent: “It’s never zero risk, but it’s pretty darn close to very low rates.” That can provide patients more peace of mind about the future, she says.

There are complications of the risk-reducing mastectomy, including:

  • Bleeding
  • Infection
  • Wound healing problems
  • Nipple ischemia, for those who have nipple-sparing mastectomy
  • Body image anxiety
  • Reconstruction complications, including wound healing problems, implant infections, scar tissue, and excessive movement of implants

Also, because the prophylactic mastectomy doesn’t eliminate the risk of breast cancer, Dr. Janfaza says some people may feel anxiety about that.

“If they have any complications down the road, they sit there and they start to think, ‘Did I really need to do this? Am I ever really going to get breast cancer?’” Dr. Janfaza says. “That, emotionally, is a very difficult pill to swallow. If you did the mastectomy because you were high-risk and you went through like flying colors, they tend to be very, very happy with their decision.”

Because of that, Dr. Janfaza says it’s important to make sure a patient is ready for surgery, both physically and emotionally.

“If you can tell a woman I can reduce your risk of getting breast cancer (by 90 percent), it’s a very good option for patients that have been identified to be that high-risk,” she says.

For more information about UPMC Hamot’s Comprehensive Breast Health Program, call 814-877-3900. If you believe you are at higher risk of breast cancer, talk to your doctor.

Sources
Guideline for Risk-Reducing Mastectomy. Agency for Clinical Innovation. Breast Cancer Facts and Figures 2019-20. American Cancer Society. Prophylactic Mastectomy: What to Expect. BreastCancer.org. Prophylactic Mastectomy Risks. BreastCancer.org. Hereditary Breast Cancer and BRCA Genes . Centers for Disease Control and Prevention. Susan M. Domchek, MD. Risk-Reducing Mastectomy in BRCA1 and BRCA2 Mutation Carriers. Journal of the American Medical Association. Surgery to Reduce the Risk of Breast Cancer . National Cancer Institute. Preventive Surgery . Susan G. Komen.

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