Why are some women opting for total mastectomy as breast cancer prevention?

March 7, 2019

If you watch the hit TV show on Bravo, Married to Medicine, you should be all too familiar with the newest cast member to the show, Dr. Contessa Metcalfe. In a recent episode, the black occupational and preventive medicine doctor openly shared her journey to preventing breast cancer as her mother passed away from the disease and her father is currently battling prostate cancer. Knowing that breast cancer runs deep within her family, she opted to undergo the elective surgery of a double (total) mastectomy. As never being diagnosed with breast cancer herself, it seems a bit drastic, but there are real pros to this prevention method. According to Cancer.gov, read why this underused option may be worth it after all:

There are two surgical options.

Technically, there are two kinds of surgeries that can be performed to reduce the risk of breast cancer in a woman who has never been diagnosed with breast cancer but is known to be at very high risk of the disease.

1. The most common risk-reducing surgery is bilateral prophylactic mastectomy (also called bilateral risk-reducing mastectomy). Bilateral prophylactic mastectomy may involve complete removal of both breasts, including the nipples (total mastectomy), or it may involve removal of as much breast tissue as possible while leaving the nipples intact (subcutaneous or nipple-sparing mastectomy).

Subcutaneous mastectomies preserve the nipple and allow for more natural- looking breasts if a woman chooses to have breast reconstruction surgery afterward. However, total mastectomy provides the greatest breast cancer risk reduction because more breast tissue is removed in this procedure than in a subcutaneous mastectomy.

Even with total mastectomy, not all breast tissue that may be at risk of becoming cancerous in the future can be removed. The chest wall, which is not typically removed during a mastectomy, may contain some breast tissue, and breast tissue can sometimes be found in the armpit, above the collarbone, and as far down as the abdomen and it is impossible for a surgeon to remove all of this tissue.

2. The other kind of risk-reducing surgery is bilateral prophylactic salpingo-oophorectomy, which is sometimes called prophylactic oophorectomy. This surgery involves removal of the ovaries and fallopian tubes and may be done alone or along with bilateral prophylactic mastectomy in premenopausal women who are at very high risk of breast cancer. Removing the ovaries in premenopausal women reduces the amount of estrogen that is produced by the body. Because estrogen promotes the growth of some breast cancers, reducing the amount of this hormone in the body by removing the ovaries may slow the growth of those breast cancers.

3. Studies have shown it to be highly effective in reducing cancer risks.

Bilateral prophylactic mastectomy has been shown to reduce the risk of breast cancer by at least 95 percent in women who have a deleterious (disease-causing) mutation in the BRCA1 gene or the BRCA2 gene and by up to 90 percent in women who have a strong family history of breast cancer (2-5).

Bilateral prophylactic salpingo-oophorectomy has been shown to reduce the risk of ovarian cancer by approximately 90 percent and the risk of breast cancer by approximately 50 percent in women at very high risk of developing these diseases.

4. It inherently may be the better choice according to your family genes and history. Women who inherit a deleterious mutation in the BRCA1 gene or the BRCA2 gene or mutations in certain other genes that greatly increase the risk of developing breast cancer may consider having bilateral prophylactic mastectomy and/or bilateral prophylactic salpingo-oophorectomy to reduce this risk.

In two studies, the estimated risks of developing breast cancer by age 70 years were 55 to 65 percent for women who carry a deleterious mutation in the BRCA1 gene and 45 to 47 percent for women who carry a deleterious mutation in the BRCA2 gene. Estimates of the lifetime risk of breast cancer for women with Cowden syndrome, which is caused by certain mutations in the PTEN gene, range from 25 to 50 percent or higher, and for women with Li-Fraumeni syndrome, which is caused by certain mutations in the TP53 gene, from 49 to 60 percent. (By contrast, the lifetime risk of breast cancer for the average American woman is about 12 percent.)

Those with a strong family history of breast cancer (such as having a mother, sister, and/or daughter who was diagnosed with bilateral breast cancer or with breast cancer before age 50 years or having multiple family members with breast or ovarian cancer) should consider the elective surgery as an option.

5. It can reduce the risk of cancer in the other breast if already diagnosed with breast cancer. Some women who have been diagnosed with cancer in one breast, particularly those who are known to be at very high risk, may consider having the other breast (called the contralateral breast) removed as well, even if there is no sign of cancer in that breast. However, doctors often discourage contralateral prophylactic mastectomy for women with cancer in one breast who do not meet the criteria of being at very high risk of developing contralateral breast cancer. For such women, the risk of developing another breast cancer, either in the same or the contralateral breast, is very small, especially if they receive adjuvant chemotherapy or hormone therapy as part of their cancer treatment.

Your health insurance may cover it.

Many health insurance companies have official policies about whether and under what conditions they will pay for prophylactic mastectomy (bilateral or contralateral) and bilateral prophylactic salpingo-oophorectomy for breast and ovarian cancer risk reduction. However, the criteria used for considering these procedures as medically necessary may vary among insurance companies. The Women’s Health and Cancer Rights Act (WHCRA), enacted in 1999, requires most health plans that offer mastectomy coverage to also pay for breast reconstruction surgery after mastectomy.

You could help stop the cycle.

If a woman has a strong family history of breast cancer, ovarian cancer, or both, she and other members of her family can obtain genetic counseling services. A genetic counselor or other healthcare provider trained in genetics can review the family’s risks of the disease and help family members obtain genetic testing on what was taken out of the patient for mutations in cancer-predisposing genes. Most women who choose this option want to get ahead of the disease and give their lives a fighting chance.

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