Should Women at High Risk for Breast Cancer Have a Mastectomy?

iStock_000015165126XSmallIf a woman finds out she is at higher risk for breast cancer, is undergoing a mastectomy to prevent the disease her best means of prevention? I sat down with Virginia Mason breast surgeon Janie Grumley, MD, to get the facts about being higher risk, having breast cancer and why major surgery may not be a patient’s best option. 

Many of us saw the coverage of actress Angelina Jolie and her decision to have a double mastectomy after testing positive for a genetic mutation on BRCA 1, increasing her risk of breast and ovarian cancer. What are the options for women who are diagnosed as higher risk, either because of genetics or other circumstances? 

Dr. Grumley:  I like to outline all the options available for high-risk patients. Today we have great screening tools for detecting breast cancer early and can apply those for ongoing surveillance. Close surveillance calls for regular breast exams with advanced imaging, including mammography and MRI that work very well for detecting breast cancer when it’s highly treatable.

There is chemoprevention, using the estrogen-inhibiting drugs tamoxifen and reloxifene that can be added with surveillance for some women. Another form of prevention people don’t talk about a lot is oophorectomy, or the removal of the ovaries. Not only is the patient helping prevent ovarian cancer, but the procedure significantly reduces estrogen production which has been shown to decrease the risk of breast cancer as well. And unlike breast cancer, we don’t have great ways of finding ovarian cancer early, or great ways of treating it. Women will experience the symptoms of menopause after oophorectomy, but they have to balance that with the benefits. Ovarian cancer is often a silent killer and would worry me more than breast cancer as a woman at higher risk for disease.

When a woman with a BRCA mutation or other risk factor chooses a double mastectomy to prevent breast cancer, she reduces her risk about 90 percent. While she may avoid frequent screening and future treatment, the procedure is not proven to affect survival. What are some other assumptions that you would caution women against making about undergoing mastectomy to prevent breast cancer? 

Dr. Grumley:  Some women may be looking at this surgery thinking they’ll be up and going in a week, will never get breast cancer, and will look and feel like they did before or even better with reconstruction. First, not everyone is a candidate for reconstruction. If a woman smokes, has diabetes or other health problems, breast reconstruction may not be an option. Second, women typically lose all sensation in their breasts with reconstruction, with numbness extending from under the breasts to the collarbone. Then there’s the challenge of recreating the nipple, which is an additional procedure involving retrieving flaps of skin to become nipples or having specialized tattoos.

Nipple-sparing mastectomies – where the breast tissue is removed while preserving the nipple area – may work well for women with relatively small breasts, but for larger breasts the cosmetic result is not as predictable. There are risks with the procedure, such as nipple ischemia, when the skin around the nipple dies. Of course infection is a risk with any procedure. If reconstruction can’t be done immediately following mastectomy, and this applies to many women for different reasons, she will have to live with the cosmetic defect and possibly the discomfort of expanders for weeks or months. I always have patients consult with a plastic surgeon early on to learn the true complexity of reconstruction and what to expect.

I tell patients the real value of having a preventive or prophylactic mastectomy is managing their fear. If they are so afraid of breast cancer that they can’t sleep at night and they worry constantly about getting the disease, then definitely there’s value in prophylactic mastectomy. But they must understand that the risk of breast cancer after surgery is not zero. There’s still a remote chance of getting another breast cancer in tissue that’s left, and because we have limited screening options following reconstruction, they must still be vigilant and follow up if they feel anything abnormal.

If a woman is diagnosed with cancer in one breast, how does that affect her treatment options? What about opting for a double mastectomy in the case of disease in only one breast?  

Dr. Grumley:  A very common concern among women with cancer in one breast is that it will spread to the other breast. But what’s more dangerous is the cancer moving to another part of the body – the lung, the liver, the bone. Many women who have cancer in one breast will never have it in the other, and if they do, we can catch it early and treat it successfully. Now if a woman has a confirmed BRCA mutation and has developed cancer in one breast, her higher risk has become reality, and she might reasonably consider a prophylactic mastectomy of the other breast. But there are still numerous treatment options for women with single breast disease that don’t involve full mastectomy.

I treat many women with cancerous tumors in one breast by removing only the tumors using plastic surgery techniques, known as oncoplastic breast surgery. This partial mastectomy leaves women with their original, reshaped breast, preserving sensation while creating a nice cosmetic result. A plastic surgeon can reshape the other breast to match in the same operation. Of course there are patients who can’t have a partial mastectomy, such as those with diffuse disease throughout the breast. But by far the majority of patients that I see, even those with large tumors or more than one tumor, are candidates for partial mastectomy using an oncoplastic approach.

Surgery is one tool among many that women can access to prevent or treat breast cancer. As a breast cancer surgeon, how do you help women manage such an important decision-making process?   

Dr. Grumley:  Treating breast cancer is not just treating the disease, it’s treating the patient. The best part of my job is getting to know that patient, learning about their life situation. It’s the only way I’ll know the best options for treating them. Maybe the service I provide won’t actually help them. This is what makes what I do more of an art. If they are considering surgery to prevent breast cancer, I help them talk through their fear. I make treatment decisions based on their needs because I’m not the one losing sleep at night.

I am very encouraging about patients getting second opinions because the more educated they become the better. But I say make sure they are listening to you as opposed to just talking to you. Notice how much information they are getting about you. It has to be a back and forth. The time spent talking in the office is just as important as the time spent in the operating room.

Comments

  1. this is really a nice conversation, and enlightened me more about the breast cancer. the most important thing of all is the awareness about a particular disease to treat it. but indeed women are still ignorant about the risk factors of breast cancer. in developed countries women are taking it seriously but in developing countries women are still taking breast cancer for granted.
    thanx for sharing the conversation that well. i have also shared a topic on breast cancer ignorance among women in the website column.

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