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Prophylactic Mastectomy is the preventive removal of the breast. It is recommended for women who have a high risk of developing breast cancer. It is almost always associated with immediate breast reconstruction.
Which women have a higher risk of developing breast cancer ?
- Women with a proven BRCA1 and BRCA2 gene mutation: this genetic abnormality predisposes to breast cancer but also to ovarian cancer.
- Women with a family history of breast cancers are strongly suspected of having this Genetic mutation, even if it cannot be identified.
- Women with extensive benign breast lesions, which predispose to breast cancer, mainly in the extensive lobular neoplasia in situ (atypical cell proliferation in the lobules) and certain extensive atypical ductal hyperplasia (atypical cell proliferation in the lactiferous ducts).
- To a lesser degree, it is known that patients who have had chest radiation at a young age (e.g. to treat Hodgkin's disease) also have an increased risk of developing breast cancer.
- Finally, women who have already had breast cancer have a higher risk of developing cancer in the other breast.
Monitoring or prophylactic mastectomy ?
Women at high risk of developing breast cancer are closely monitored, with a consultation every six months, alternating mammogram, ultrasound and Biopsy MRI (in the case of a proven genetic mutation), biopsy in the slightest case of doubt. This close monitoring helps to diagnose and treat any possible cancerous lesions early on but does not prevent cancer from occurring. The majority of women at high risk opt for this solution: in France, over 90% of women with the Genetic mutation choose not to have a mastectomy, and to be checked regularly.
Monitoring can help to diagnose early-stage cancers but does not prevent their occurrence. When the risk is very high, as is the case for women carrying the BRCA1 or 2 genetic mutation, a prophylactic mastectomy is sometimes requested by the patient. It is currently the only effective method for preventing the development of breast cancer. The risk after a bilateral Mastectomy is very low: it is not nil but it drops to less than 5% (compared to 40-75% in the case of a proven mutation).
- If the mutation concerns the gene BRCA1, the prophylactic mastectomy is planned from the age of 30 years, because there is a risk of developing breast cancer at a very young age.
- If the mutation affects the gene BRCA2, the risk is lower and the decision depends on what age the onset of cancer occurred among other family members.
In all cases of BRCA1 or 2 mutations, an adnexectomy should be considered (removal of ovaries and fallopian tubes), even if the breasts are conserved. The benefits of an adnexectomy are twofold. The procedure considerably reduces the risk of ovarian cancer (which is between 20 and 40%, compared to XXXX% in women without the mutation). It has also been shown that adnexectomy reduces the risk of breast cancer by half.
Prophylactic mastectomy: a difficult decision
Over the last fifteen years, advances in the field of breast cancer have enabled patients affected by breast cancer to avoid having a Mastectomy (removal of the breast) in a large number of cases. Today, the breast is conserved in more than 70% of cases. Paradoxically, in the case of prophylactic Mastectomy, healthy and fairly young women must undergo removal of the breasts. For some, as difficult as it may be, the choice has a clear argument: they have a proven genetic mutation (mutation of genes BRCA1 or BRCA2) or their history suggests a statistically significant risk of developing cancer and they are not prepared to accept this risk. For others the decision is more complicated. This is particularly true for women who are not carrying an identified genetic mutation and have never developed the disease but whose family history suggests that they are genetically predisposed to it. In these cases, doctors are in favour of monitoring but some patients sometimes may consider a Mastectomy based on personal risk, which is impossible to assess given the current state of knowledge.
When a mutation is identified in a family and one parent has the mutation, each of their children has a one in two chance of carrying the same mutation and an even chance of not having inherited it. With regard to breast cancer, genetic analyses can identify women carrying the mutation of genes BRCA1 or BRCA2 and therefore reassuring patients who have a mutation identified in the family but who do not have the mutation themselves. But there are some cases where a Genetic mutation is strongly suspected in the family but has not been found (because it is currently unknown). Unfortunately, in this case, the women of the family at risk cannot know whether or not they carry the mutation.
Medical and psychological care for prophylactic mastectomy: helping with the decision
The decision should be taken after careful consideration and consultation with the various specialists involved. This decision is never an urgent one and is very closely supervised :
- Consultation with the onco-geneticist assesses the risk of developing breast cancer. They can assess a 'risk' even if the mutation is not diagnosed
- Consultation with the surgeon and gynaecologist enables the patient to consider all the options: close monitoring (once or twice a year) with ultrasound, mammography and MRIor prophylactic surgery to remove the ovaries and fallopian tubes (systematically proposed) or even a prophylactic mastectomy
- Prophylactic mastectomy often has a psychological impact which is hard to predict before surgery. Weakened by the fear of cancer, a woman can feel relieved by the thought that she might significantly reduce the risk of cancer by having a mastectomy. Then once the risk becomes more remote she can sometimes struggle to cope with her reconstructed breasts, given that she was not ill in the first place, and she might find it hard to accept a result that she is not satisfied with. This is why psychological support is always offered to women who undertake this process, even before any decision is made.
Reconstruction after prophylactic mastectomy
Two mastectomy techniques might be proposed: mastectomy with conservation of the breast skin and removal of the nipple and areola; or mastectomy with conservation of the nipple and areola. Women often choose a procedure which minimises scarring and keeps the areola, nipple and covering skin, in order to achieve the best possible cosmetic result.
Reconstruction is almost always carried out at the same time as the mastectomy. Pre-operative consultation with a plastic surgeon helps to address the various possible reconstruction techniques, to assess the expected results and the complications that could be envisaged, which are always possible and are even more distressing for patients who feel healthy. In most cases, a bilateral prophylactic mastectomy is combined with a reconstruction using prosthesis, and very rarely with a flap reconstruction (in other words, using the patient's own tissue)