{{short description|Surgical removal of the breasts to reduce breast cancer risk}} {{cs1 config|name-list-style=vanc|display-authors=6}} {{Infobox medical intervention | name = Preventive mastectomy | synonym = | image = | caption = | alt = | pronounce = | specialty = general surgeon/plastic surgeon | synonyms = | ICD10 = | ICD9 = | ICD9unlinked = | CPT = | MeshID = | LOINC = | other_codes = | MedlinePlus = | eMedicine = }} A '''preventive mastectomy''' or '''prophylactic mastectomy''' or risk-reducing mastectomy (RRM) is an elective operation to remove the breasts so that the risk of breast cancer is reduced.<ref name=mayo>{{cite web |url=http://www.mayoclinic.com/health/prophylactic-mastectomy/WO00060| author=Mayo Clinic staff |title=Prophylactic mastectomy: Surgery to reduce breast cancer risk |publisher=Mayo Clinic | access-date=2013-05-14}}</ref><ref name=nci>{{cite web |url=http://www.cancer.gov/cancertopics/factsheet/Therapy/preventive-mastectomy |author=NIH staff |title=Preventive Mastectomy |publisher=National Cancer Institute |access-date=2013-05-14}}</ref>
==Indications== The procedure is a surgical option for individuals who are at high risk for the development of breast cancer. High risk women without a prior history of personal breast cancer might consider bilateral risk-reducing mastectomy (BRRM) as an option for minimising the risk of primary breast carcinoma development.<ref>{{cite journal | vauthors = Eisemann BS, Spiegel AJ | title = Risk-Reducing Mastectomy and Breast Reconstruction: Indications and Evidence for Current Management Strategies | journal = Clinics in Plastic Surgery | volume = 45 | issue = 1 | pages = 129–136 | date = January 2018 | pmid = 29080654 | doi = 10.1016/j.cps.2017.08.013 }}</ref> The procedure includes the surgical removal of both breasts before any pathologic diagnosis has been made. Women that were previously diagnosed with a breast cancer in one breast (ipsilateral breast cancer) might elect to undergo risk-reducing mastectomy of the other unaffected (contralateral) breast, that is to say contralateral risk-reducing mastectomy (CRRM), to minimize the risk of a second breast cancer development. CRRM has been shown to reduce the incidence of contralateral breast cancer, but there is not sufficient evidence that it improves survival.<ref>{{cite journal | vauthors = Carbine NE, Lostumbo L, Wallace J, Ko H | title = Risk-reducing mastectomy for the prevention of primary breast cancer | journal = The Cochrane Database of Systematic Reviews | volume = 4 | issue = 4 | article-number = CD002748 | date = April 2018 | pmid = 29620792 | pmc = 6494635 | doi = 10.1002/14651858.CD002748.pub4 | collaboration = Cochrane Breast Cancer Group }}</ref> Women who had a bilateral mastectomy in 2013 were about 10 years younger than those who had a unilateral mastectomy.<ref>{{cite journal | vauthors = | title = Trends in Bilateral and Unilateral Mastectomies in Hospital Inpatient and Ambulatory Settings, 2005–2013 | journal = HCUP Statistical Brief | issue = 201 | pages = 1–14 | date = 2016 | pmid = 27253008 | url = http://www.hcup-us.ahrq.gov/reports/statbriefs/sb201-Mastectomies-Inpatient-Outpatient.pdf | access-date = 7 March 2016 }}</ref>
This preventive operation pertains to women with these characteristics:<ref name=nci/> * BRCA1 or BRCA2 mutation carriers; this is the main indication for bilateral prophylactic mastectomy.<ref>{{cite journal | vauthors = Zagouri F, Chrysikos DT, Sergentanis TN, Giannakopoulou G, Zografos CG, Papadimitriou CA, Zografos GC | title = Prophylactic mastectomy: an appraisal | journal = The American Surgeon | volume = 79 | issue = 2 | pages = 205–212 | date = February 2013 | pmid = 23336662 | doi = 10.1177/000313481307900233 | s2cid = 23664548 | doi-access = free }}</ref> * Cancer in one breast and a family history of breast cancer. * Family history of breast cancer. The genetic risk can be passed down through the mother's or father's side. * Radiation therapy to the chest before the age of 30. * Presence of high-risk breast lesions like lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH).<ref>{{cite journal | vauthors = Burke EE, Portschy PR, Tuttle TM | title = Prophylactic mastectomy: who needs it, when and why | journal = Journal of Surgical Oncology | volume = 111 | issue = 1 | pages = 91–95 | date = January 2015 | pmid = 24965368 | doi = 10.1002/jso.23695 }}</ref> * Having dense breasts or breasts with diffuse microcalcification, as the screening for breast cancer is made difficult.
Discussions and decision should be made with the help of specialists who can use relevant information and statistical models to predict the individual lifetime risk of development of breast cancer.
Undergoing a preventive mastectomy does not guarantee that breast cancer will not develop later, however, it reduces the risk by 90% in high risk women.<ref name=nci/><ref name=scheufler/> Also, a preventive mastectomy may not be able to remove all breast tissue as some of it may be in the arm pit, near the collar bone, or in the abdominal wall.<ref name=mayo/>
Male carriers of BRCA1 and BRCA2 mutations have a higher risk of breast cancer than other males, approximately 1.2% and 6.8%,<ref>{{cite journal | vauthors = Tai YC, Domchek S, Parmigiani G, Chen S | title = Breast cancer risk among male BRCA1 and BRCA2 mutation carriers | journal = Journal of the National Cancer Institute | volume = 99 | issue = 23 | pages = 1811–1814 | date = December 2007 | pmid = 18042939 | pmc = 2267289 | doi = 10.1093/jnci/djm203 | author-link2 = Susan Domchek }}</ref> but their risk is much lower than in female mutation carriers (about 60%) and lower than in the general female population (12%).<ref>{{cite web|date=January 30, 2018|title=BRCA mutations: cancer risk and genetic testing|url=http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA|access-date=9 July 2020|publisher=National Cancer Institute}}</ref> Thus, preventive mastectomy has not been advocated for affected men.
==Procedure== {{main|Mastectomy}} In most situations the operation involves both breasts and thus represents a bilateral procedure. When cancer has affected already one breast, the other breast, still healthy, may be removed in a unilateral preventive mastectomy. Typically either a simple, a subcutaneous or a nipple-sparing mastectomy is performed. With the former the areola and nipple are removed, while the other two approaches preserve the nipple area for cosmetic reasons. To increase the viability of the nipple area for preservation during mastectomy, a so-called "nipple delay" procedure can be done several weeks before the mastectomy.<ref>{{cite journal | vauthors = Jensen JA, Lin JH, Kapoor N, Giuliano AE | title = Surgical delay of the nipple-areolar complex: a powerful technique to maximize nipple viability following nipple-sparing mastectomy | journal = Annals of Surgical Oncology | volume = 19 | issue = 10 | pages = 3171–3176 | date = October 2012 | pmid = 22829005 | doi = 10.1245/s10434-012-2528-7 | s2cid = 207173683 }}</ref> Reconstructive breast surgery can be performed in the same surgical setting, added after the mastectomy.<ref name=metcalfe>{{cite journal | vauthors = Metcalfe KA, Semple JL, Narod SA | title = Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: a descriptive study | journal = Plastic and Reconstructive Surgery | volume = 114 | issue = 2 | pages = 360–366 | date = August 2004 | pmid = 15277800 | doi = 10.1097/01.PRS.0000131877.52740.0E }}</ref> Saline or silicone implants may be used in the reshaping process and may be placed in a later setting.<ref name=jolie>{{cite web |url=https://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html?hp |author=Angelina Jolie| title=My Medical Choice| work=New York Times| date=2013-05-14| access-date=2013-05-15|author-link=Angelina Jolie}}</ref>
A preventive mastectomy carries certain risks including those of anesthesia, bleeding, infection, pain, disfiguration, anxiety and disappointment.
After surgery, routine screening for breast cancer is recommended.<ref name=nci/>
==Alternatives== There are other options to reduce the risk of future breast cancer.<ref name=nci/> Intensified breast cancer screening for high risk women may detect cancer at an early, treatable stage. Certain medications that block the effect of estrogen (i.e. tamoxifen, raloxifen, exemestane) can reduce the risk by about 50% but also have side effects. Prophylactic salpingo-oophorectomy reduces estrogen levels and the risk of both ovarian and breast cancer, however, the reduction in breast cancer risk is about 50% in high risk women<ref name=scheufler>{{cite journal | vauthors = Scheufler O, Fritschen U | title = [Prophylactic mastectomy in women at high risk for breast cancer: indications and options] | journal = Handchirurgie, Mikrochirurgie, Plastische Chirurgie | volume = 40 | issue = 4 | pages = 239–247 | date = August 2008 | pmid = 18716986 | doi = 10.1055/s-2008-1038774 }}</ref> as compared to 90% when preventive mastectomy is done. Lifestyle changes (in weight, diet, exercise, avoidance of smoking, limiting alcohol) may reduce the risk to some degree.<ref>{{cite journal | vauthors = Eliassen AH, Hankinson SE, Rosner B, Holmes MD, Willett WC | title = Physical activity and risk of breast cancer among postmenopausal women | journal = Archives of Internal Medicine | volume = 170 | issue = 19 | pages = 1758–1764 | date = October 2010 | pmid = 20975025 | pmc = 3142573 | doi = 10.1001/archinternmed.2010.363 }}</ref>
==Acceptance== A factor that facilitates the decision to undergo a preventive mastectomy is that results of breast reconstructive surgery have improved.<ref name=npr/> A 2004 Canadian study found that 70% of women were satisfied or extremely satisfied with the reconstruction after bilateral prophylactic mastectomy.<ref name=metcalfe/> In the United States preventive mastectomy is gaining increased acceptance.<ref name=npr/><ref>{{cite web| url= http://www.thedailybeast.com/newsweek/2008/08/26/no-guarantees.html |title=No Guarantees| publisher=Newsweek| date=2008-08-26 |access-date=2013-05-14}}</ref> The decision of famous actresses such as Christina Applegate and Angelina Jolie<ref name=jolie/> to undergo preventive mastectomy has given the procedure wider media attention.<ref name=npr>{{cite web| url=https://www.npr.org/blogs/health/2013/05/14/183892507/angelina-jolie-and-the-rise-of-preventive-mastectomies |author=Nancy Shute| title=Angelina Jolie And The Rise Of Preventive Mastectomy| publisher=NPR| date=2013-05-14 |access-date=14 May 2013}}</ref> The trend towards prophylactic mastectomy appears to be less pronounced in Europe<ref name=npr/> and India.<ref name=hindu>{{cite news| vauthors = Kannan R |title=Angelina example may spread prophylactic mastectomy in India|url=http://www.thehindu.com/todays-paper/tp-national/angelina-example-may-spread-mastectomy-awareness-in-india/article4716495.ece|access-date=15 May 2013|newspaper=The Hindu|date=15 May 2013}}</ref>
== References == {{reflist}}
Category:Breast cancer Category:Breast surgery Category:Obstetrical and gynaecological procedures Category:Surgical oncology Category:Surgical removal procedures