Prophylactic Mastectomy

With an annual incidence of 252,700 cases in the United States and 41,000 deaths, breast cancer is still the most prevalent cancer in women, coming in second only to lung cancer. A woman's lifetime risk of receiving a breast cancer diagnosis is 12.5% and rises with age, with the prevalence in 2014 reaching 3,346,380 cases. Breast cancer incidence changed between 1975 and 2014, according to the surveillance, epidemiology, and end results (SEER) database. Between 1975 and 1980 and between 2004 and 2014, there were 0.5 and 0.4 reported yearly percent changes, respectively. Changes in female reproductive habits and the introduction of more aggressive screening methods, which have boosted disease diagnosis, can be used to explain a rise in breast cancer incidence throughout the 1980s. Family history, genetic mutations, lifestyle, radiation exposure, pregnancy, prior history, and other factors are among the numerous and complex risk factors for developing breast cancer, which can also be influenced by the clinical features and the primary cancer treatment method. The rate of recurrence often increases in the first few years following the first breast cancer diagnosis and then drops. To lower the risk of breast cancer development and recurrence, a variety of interventions have been put in place.

What is a Prophylactic Mastectomy?

A prophylactic mastectomy involves removing one or both breasts as a preventative procedure to lower the risk of breast cancer. The procedure may also be referred to as a preventive or risk-reducing mastectomy. The National Cancer Institute (NCI) states that if you have a very high chance of developing breast cancer, a preventive mastectomy can lower your risk by up to 90%. Based on a variety of criteria, a very high risk indicates you have at least a 20% lifetime probability of having breast cancer.

Breast Cancer Risk Factors

Some women who carry a BRCA1 or BRCA2 gene mutation have a lifelong risk of ovarian cancer of 54% and a breast cancer risk of up to 89%. Other risk factors that put the patient at risk of developing breast cancer:

Hereditary mutation in the BRCA1 or BRCA2 genes (genes that contribute to the production of proteins that repair DNA damage). Additionally, if you have a high prevalence of one of the other genes linked to an increased risk of breast cancer, such as ATM, TP53, CDH1, or PTEN, you are also more likely to get breast cancer. Cancer is the uncontrolled growth of aberrant cells, which can occur when certain genes mutate and cause cells to grow uncontrollably. According to the US Centers for Disease Control and Prevention (CDC), 5 to 10% of breast cancers are thought to have hereditary origins. Genetic testing can determine if you inherit these.
Having received chest radiotherapy before the age of 30. It's possible that you underwent radiation therapy for your chest as a kid to treat a different malignancy, such as non-Hodgkin or Hodgkin lymphoma. As you age, the radiation makes breast cancer more probable.
Having several close relatives who have or have had breast cancer, ovarian cancer, or at least one close relative who got a young-onset breast cancer diagnosis. You may have a sister, mother, or daughter who is a close relative. Males who were diagnosed with breast cancer are close relatives as well.
History of breast cancer. New cancer in your other breast is more likely to grow if you've already had breast cancer than if you haven't.
Having lobular carcinoma in situ (LCIS) discovered. LCIS is a disorder where abnormal cells are identified in your breast's tiny lobes; it is not cancer. Breast cancer in either breast is more likely to develop if you have LCIS. The majority of breast surgeons will, however, agree that LCIS alone is not a ground for prophylactic mastectomy. Other risk factors need to emerge as well.

Prophylactic Mastectomy Indications

A woman can anticipate having a 1.5% probability of developing breast cancer if she has no family history of the disease and no genetic risk factors. For these low-risk women, prophylactic mastectomy (the removal of both breasts before cancer develops) is not medically advised.

However, the risk is substantially higher for women who have a family history or certain genetic markers. Actress Angelina Jolie revealed that she had an 89% probability of developing cancer when she underwent the commonly publicized prophylactic mastectomy. Doctors may advise a prophylactic mastectomy in these cases.

To choose which procedure is best for them, patients should talk to their doctor about their medical history. High-risk patients should be directed to a genetic counselor so that they may evaluate their medical history and personal and family history to see if genetic testing might be appropriate for them. Today's mastectomy procedures are very different from those practiced even ten years ago. The reconstruction, which is typically done as a second stage of the mastectomy operation, produces good outcomes with little scarring and cosmetic outcomes that are visually attractive.

Prophylactic Mastectomy Types

The most frequent risk-reducing procedure is a bilateral prophylactic mastectomy, often known as a bilateral risk-reducing mastectomy, which involves removing both breasts. Options consist of:

Nipple-sparing mastectomy. The surgeon may excise as much breast tissue as possible during a subcutaneous or nipple-sparing mastectomy while yet leaving your nipples intact. The benefit of the nipple-sparing mastectomy is that your breast reconstruction will appear more natural if you decide to get it. Women with small to medium-sized breasts should choose this option.
Skin-sparing mastectomy. During this treatment, the doctor just removes the scar from your first biopsy and the skin from your nipple and areola. The breast tissue is then removed by the surgeon using a little incision that has been made. The skin is now available for quick reconstruction, either with an implant or your tissue.
Total mastectomy. If you opt for a total mastectomy, the doctor will remove both of your breasts, along with your nipples. A total mastectomy has the advantage of removing more breast tissue than a nipple-sparing or skin-sparing mastectomy; with minimal to no breast tissue remaining, your risk of developing breast cancer is marginally higher. Even this method isn't perfect, though. The cause is that not all of the malignant breast tissue can be removed. Breast tissue may be present in your chest wall, but a mastectomy normally does not eradicate it. Additionally, breast tissue may be present in your armpits, close to your collarbone, and below.

Prophylactic Mastectomy Procedure

One or both breasts are removed by the physicians during the surgery. You could wish to have breast reconstruction done simultaneously if you decide to have a prophylactic mastectomy. The skilled surgeons will go over all your options with you and guide you in making the best decision possible. The procedure for prophylactic mastectomy is done while the patient is unconscious. Depending on whatever reconstruction technique is used and whether reconstruction is done concurrently, aspects of the procedure will vary.

The breast tissue is separated from the chest wall and removed during a mastectomy through a small incision performed along the inframammary fold (the fold below the breast). There is no cutting of the chest wall muscles. The lymphatic and blood vessels that feed the breast tissue are detected and clamped. In a prophylactic mastectomy, the nipple is not removed but rather may be repositioned on the breast surface. Each breast typically has a tiny drain installed to drain fluid for a few days after surgery. Sutures are used to close the incisions; they will be removed at your first postoperative appointment or they might break on their own.

Prophylactic Mastectomy Recovery

Pain will be present during the first few days following surgery. Usually, doctors will prescribe pain medication, which should be enough to ease any discomfort.

The majority of patients discover that their postoperative pain is at its worst within the first 24 to 48 hours and starts to subside on the second or third day. Up to six weeks after surgery, a dull soreness in your chest wall could persist.

During the procedure, tiny tubes called surgical drains are placed to remove fluid from your chest. Depending on how much fluid they collect, they are typically removed two to four days after surgery. When you are admitted to the hospital and when you are returned home, you will receive detailed instructions for drainage care.

Showering is permitted 48 hours following drain removal or as determined by your doctor. Showering is okay, but avoid immersing your wounds in water until all of your sutures have been taken out.

Prophylactic Mastectomy Risks

It's crucial to comprehend the advantages and risks of a preventative mastectomy before making a decision. After a prophylactic mastectomy, there is a danger of infection or bleeding, as well as pain, soreness, or swelling in the breast region, much like with any surgical procedure.

As you adapt to your new body, having a prophylactic mastectomy may also change how your body feels and looks. This can have an emotional, psychological, and physical impact. Following surgery, you can have a new perspective on your body or suffer from body image. After missing sensation in your breast and nipple, you could also have to deal with changes in your sexual orientation. Recognize that your support network and others can assist you in resolving these problems and finding the things you need to continue. Inquire about resources available following a prophylactic mastectomy from your medical team.

Prophylactic Mastectomy Alternatives

You have other options besides a prophylactic mastectomy to lower your risk of breast cancer. This should you discuss with your doctor.

Enhanced Screening

Breast cancer screening, also known as enhanced screening, should be conducted more frequently in women who are at high risk of developing the disease.

The American Cancer Society advises high-risk women to start screening at age 30 or at whatever age their doctor thinks is appropriate given their medical and family history.
To maximize your chances of discovering any cancer in its earliest stages, it is advised that you schedule your MRI and mammogram, having one every six months.
Radiation imaging procedures may increase the risk of breast cancer if you have gene alterations that make you more likely to get the disease. The several screening methods and which are best for you should be discussed with your doctor.

Chemoprevention

Tamoxifen and raloxifene, two medications that can be taken proactively to lower the chance of getting breast cancer, have received FDA approval. In breast cells, both medications inhibit estrogen. The extent to which these medications reduce the risk of breast cancer is still being studied. According to the American Cancer Society, several studies have indicated that they may reduce the risk by roughly 40%. They may cause negative effects like:

Symptoms of menopause
Blood clots
Uterine cancer

Other Medications

The estrogen-lowering effects of aromatase inhibitors like anastrozole and exemestane may reduce your risk of developing breast cancer. The FDA hasn't yet given them the approval to reduce the risk of breast cancer, though. Some undesirable effects of aromatase inhibitors include:

Menopause symptoms include hot flashes and nocturnal sweats
Joint and muscle discomfort
Bone thinning that causes osteoporosis and brittle bones
High cholesterol

Healthy Lifestyle

Some common components have been demonstrated to lower the risk of breast cancer. These consist of:

Being healthy in regards to weight
Regularly exercising
Limit alcohol consumption
Avoiding hormone medication while a woman is menopausal

Removing Ovaries

Sometimes this procedure is referred to as a prophylactic oophorectomy. Your ovaries and fallopian tubes will be removed. It is performed on premenopausal women who are at a high risk of getting breast cancer because estrogen, which is produced by the ovaries, has been shown to accelerate the growth of some breast cancers. By removing the ovaries, you lower your body's estrogen levels, which may prevent the development of breast cancer.

You will experience medically induced menopause as a result of this operation. Hot flashes, sleeplessness, stress, sadness, and a loss of bladder control are among the symptoms of menopause that can occur on their own. Reduced sex desire and dry vagina can both be side effects of surgical menopause.

According to the American Society of Clinical Oncology, salpingo-oophorectomy has been found to lower the incidence of breast cancer by about 50% and ovarian cancer by about 90% in women who are at a very high risk of acquiring both diseases.

Some women choose to have both their breasts and ovaries removed. You might want to talk to your doctor about menopausal hormone therapy if you decide to have both removed. Even while some hormone therapies increase the risk of breast cancer, bilateral prophylactic mastectomy and salpingo-oophorectomy have significantly decreased that risk.

Conclusion

The overwhelming body of research supports an 85% to 100% decrease in breast cancer incidence following preventative bilateral and contralateral mastectomy. Prophylactic ipsilateral mastectomy, on the other hand, has not been demonstrated to completely remove the risk of recurrence and is typically not recommended unless surgically required. Absolute survival advantages would necessitate studies with a bigger patient population and longer follow-up times because many breast cancers are discovered at an early stage where patients have a good prognosis. Although prophylactic mastectomy is generally safe and has a high satisfaction rate, it is important to carefully estimate the risks and choose those who will benefit from preventing breast cancer to reduce morbidity from the procedure.