Breast cancer prevention and early detection have greatly evolved in recent years.
On the one hand, we are witnessing increased media coverage and improved public awareness. On the other hand, accessibility to genetic testing has created new prevention possibilities. Nowadays, women can take a more informed approach to breast cancer prevention. For some women, who are at high risk for developing breast cancer, this prevention approach can include opting for prophylactic mastectomy.
Studies have shown that women at high risk for developing breast cancer, who opted for a prophylactic mastectomy, reported a decrease in emotional concern for developing breast cancer 1 and high satisfaction with the procedure. 2 Nevertheless, this approach is not suitable for everyone. Prophylactic mastectomy is an irreversible procedure with a high physical and psychological impact that needs careful consideration.
In this blog post, we will explore who might be at a higher risk for developing breast cancer and some of the surgical interventions available to those who want to be proactive against the disease.
Risk factors
Being born a female is the main risk factor for developing breast cancer. Male breast cancer is rare, representing approximately 1% of cancers that occur in men and approximately 1% of all breast cancers worldwide.3
The risk for breast cancer is not the same for all women and each woman may have a different risk level for developing breast cancer, depending on several health factors and their family history. Even for women in their 20’s and 30’s, discussing their individual breast cancer risk with their healthcare provider is encouraged.4
A "high-risk" designation can result from a single factor or a combination of factors, including:5
- A mutation in the BRCA1 & BRCA2 gene or any gene associated with an increased risk of breast cancer.
- A significant family history of breast cancer, characterized by multiple cases among close relatives or the occurrence of breast cancer in at least one relative at a young age.
- Previous chest radiation therapy before the age of 30.
- A history of unilateral breast cancer or of ovarian cancer.
Should I have genetic testing?
Genetic tests are performed to search for inherited mutations in the BRCA1 and BRCA2 genes or less commonly in genes such as PTEN or TP53.6
About 5% to 10% of breast cancer cases are thought to be hereditary, meaning that they result directly from gene mutations passed on from a relative. Therefore, genetic testing will not detect all risk profiles for breast cancer and it is recommended in specific instances.7
If you have been diagnosed with breast cancer or have any of the risk factors that put you at higher risk levels – such as a significant family history – you may be a good candidate for genetic testing.
As not every woman needs to be tested, the best way to know if genetic testing is suitable for you is discussing your risk profile and your options with your medical care provider.
Medical approaches:
Opting for preventive surgery isn't typically advisable for women at an average or slightly above average risk of breast cancer.
Prophylactic mastectomy is a procedure with its own risks and with physical and psychological consequences that need to be weighed against the cancer risk the procedure is designed to reduce.
The strategies discussed in this article are typically reserved for women facing a significant risk of developing the disease.
Approach for patients with unilateral sporadic breast cancer
Patients with unilateral sporadic breast cancer face a slightly elevated risk of developing an invasive contralateral breast cancer (CBC).
The majority of women will never experience a contralateral breast cancer, but risk-reducing measures such as a contralateral prophylactic mastectomy (CPM) might be appropriate for some patients, it may also provide some peace of mind.8
A contralateral prophylactic mastectomy (CPM), also referred to as contralateral risk-reducing mastectomy is the removal of the unaffected breast in women who developed unilateral primary breast cancer.
Approach for patients with gene mutation or high risk of developing breast cancer
For women in this group, having a bilateral prophylactic mastectomy before cancer is diagnosed can greatly reduce (but not eliminate) the risk of getting breast cancer.
Women with a BRCA1 or BRCA2 mutation have a high risk of developing breast cancer and ovarian cancer. Therefore, a prophylactic oophorectomy (removal of the ovaries) might be also recommended.9
Most doctors recommend that women with a BRCA1 or BRCA2 mutation wait to have their mastectomy and oophorectomy after having children, with some women opting to combine both in a single procedure.10
Unfortunately, there is no way to predict if a woman will benefit from these surgeries. Most women with a BRCA1 or BRCA2 gene mutation will develop breast cancer at some point in their lives and having a prophylactic mastectomy before the cancer develops might be very beneficial. But not all women with BRCA1 or BRCA2 mutations will develop breast cancer.11
Reconstructing the breast after contralateral prophylactic mastectomy or bilateral prophylactic mastectomy
Once the mastectomy is performed and the risk of breast cancer is reduced, women can opt for a breast reconstruction. The breast reconstruction journey will depend on different considerations, including the surgeon’s recommendation, personal preferences, physical condition and medical needs.
Patients can opt for immediate breast reconstruction - during the same procedure of the mastectomy, or a delayed breast reconstruction at a later date.
This decision is highly personalised and should align with each individual's unique circumstances and desired timeline.
You can learn more about the different methods for breast reconstruction here.
In conclusion, it is crucial to engage in open discussions with your healthcare team to gain a thorough understanding of the potential benefits, risks, and side effects associated with the preventive treatment options available in case of high risk of breast cancer. You might also want to talk to other women who have had this surgery before deciding if it’s right for you.
Remember, your healthcare decisions are personal, and by actively participating in these conversations, you empower yourself to make choices that align with your personal needs and well-being.
Sources:
1. https://pubmed.ncbi.nlm.nih.gov/10891963/
2. https://pubmed.ncbi.nlm.nih.gov/16204003/
3. https://link.springer.com/article/10.1007/s10549-018-4921-9
4. https://www.summahealth.org/flourish/entries/2021/10/what-does-high-risk-for-breast-cancer-really-mean#:~:text=One%20out%20of%20every%20eight,breast%20cancer%20over%20a%20lifetime.
5. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/preventive-surgery-to-reduce-breast-cancer-risk.html
6. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/breast-cancer-risk-factors-you-cannot-change.html#:~:text=If%20you%20have%20inherited%20a,members%20have%20had%20breast%20cancer.
7. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/breast-cancer-risk-factors-you-cannot-change.html#:~:text=If%20you%20have%20inherited%20a,members%20have%20had%20breast%20cancer.
8. https://www.uptodate.com/contents/contralateral-prophylactic-mastectomy
9. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/preventive-surgery-to-reduce-breast-cancer-risk.html
10. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/preventive-surgery-to-reduce-breast-cancer-risk.html
11. https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/preventive-surgery-to-reduce-breast-cancer-risk.html