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Breast Risk Reducing Surgery

Clinical decision-making around which strategies should be pursued for risk-reduction involves a trade-off between life expectancy and quality of life (risk-reducing surgery, surveillance, and/or chemoprevention)

The decision about whether or not to undergo surgery is based on the patient’s personal preference, given that there is effective screening available.

This section is written to provide you with some useful information to assist you during the consult.

Our team at NZFCS offer a multidisciplinary approach to help your patient make an informed choice when considering risk-reducing prophylactic mastectomy.

Definition

  • Simple mastectomy – removal of the breast tissue including skin
  • Skin sparing mastectomy – removal of the breast tissue preserving the breast skin envelope with a view to immediate reconstruction
  • Nipple preserving mastectomy – removal of the breast tissue preserving both the breast skin envelope and the nipple areolar complex (NAC)

Clinical Indications

  • Women with BRCA1 and BRCA 2 mutations
  • Women with a strong family history of breast and or ovarian cancer without a genetic mutation
  • Women who have a strong family history of breast and or ovarian cancer who choose not to have genetic testing
  • Gains in life expectancy decrease with age at the time of risk-reducing surgery. Such gains are minimal for 60-year old women

Counselling

  • Women should be counselled preoperatively about the potential morbidity of the procedures, including reconstruction
  • Women should be counselled that surgery may impact body-image, libido and sexual functioning
  • The possibility of breast cancer being diagnosed histologically following a risk-reducing mastectomy should be discussed pre-operatively
  • All women considering risk-reducing surgery should be able to discuss their reconstructive options with a surgical team member with specialist oncoplastic or reconstructive skills

How Surgery is Performed

  • Patients who opt to proceed with mastectomy should undergo bilateral total mastectomy rather than subcutaneous mastectomy (latter leaves behind more glandular tissue that remains at risk for future cancers Rebbeck, Guillem)
  • Skin-sparing mastectomy (with or without preservation of the nipple-areolar complex followed by immediate breast reconstruction is increasingly being performed as it provides superior cosmetic results
  • Although longer follow-up of women undergoing a skin-sparing mastectomy is needed, it is considered to be an acceptable option for risk-reduction (Peled)
  • If SSM and NSM performed skin flaps with a thickness <5mm should be aimed for and 2-3mm NAC

What Should be Discussed at the Consult?

Lifetime risks of breast cancer

  • The lifetime risk of breast cancer in a BRCA1 mutation carrier is 57%
  • The lifetime risk of breast cancer in a BRCA 2 mutation carrier is 49%
  • The lifetime risk of breast cancer in a Li Fraumeni syndrome is —
  • The lifetime risk of breast cancer in a CDH1 mutations is 42%
  • The lifetime risk of breast cancer in Peutz Jeghers is 45% by 70y

How much benefit is the surgery to cancer risk?

  • There is a >90% reduction in the risk of breast cancer
  • To date, no mortality benefit has been demonstrated from risk-reducing breast surgery
  • Most studies focus on BRCA mutation carriers
  • In the Prevention of Surgical Endpoints (PROSE) multicenter prospective cohort study showed that the surgical group had a lower all-cause mortality, breast cancer specific mortality and ovarian cancer specific mortality

What is the risk of surgery?

  • Risk-reducing mastectomy can be associated with significant potential morbidity related to both the mastectomy and reconstruction
  • The reconstruction chosen impacts significantly on the period of recovery from surgery and spectrum of potential complications
  • Surgery may impact body-image, libido and sexual functioning
  • Complications can include pain, infection and need for revisional surgery.
  • Most complications are related to mastectomy site or reconstruction and are generally short-lived

Timing of Surgery

  • Given the effective surveillance strategies for breast cancer, the timing of surgery should be driven by the patient
  • Gains in life expectancy decline with age at the time of risk-reducing mastectomy and are minimal for 60-y old women
  • One decision analysis model (Kurian) suggested that prophylactic mastectomy at 25 plus BSO at 40 maximised survival probability

Why do Women Choose Risk Reducing Surgery?

  • Proven in research to be effective in reducing risk of breast cancer.
  • Way of taking control of anxiety producing situation

Why do Women Choose Not to Have Surgery?

  • Concerns regarding the side effects – body image and sexuality implications
  • Not the right time for them
  • Alternative options – effective surveillance strategies (mammography and MRI)
  • Perception of risk
  • Does not eliminate the risk to zero

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