Preventive Surgery for Women at High Risk of Breast Cancer

For women who have a very high risk of getting breast cancer, preventive surgeries (also known as risk-reducing surgeries) might be an option to reduce that risk significantly. Women are said to have a high risk of getting breast cancer are those who have:

• A disease-causing gene mutation in the BRCA1, BRCA2, TP53 or PALB2 genes that is linked to an increased risk of breast cancer
• Strong family history of breast cancer (such as a history of breast cancer/ovarian cancer or breast cancer before the age of 50 in one’s mother, sister and/or daughter)
• Lobular Carcinoma in Situ (LCIS) plus a family history of breast cancer
• Had radiation to the chest before the age of 30 (such as for treatment of Hodgkin lymphoma)

There are several types of preventive surgeries that one may consider.

Bilateral prophylactic mastectomy refers to the removal of both breasts to reduce the risk of getting breast cancer. It can be performed in several ways to achieve different outcomes:

• Total mastectomy (complete removal of both breasts, including the nipples)
• Subcutaneous or nipple-sparing mastectomy (removal of as much breast tissue as possible while leaving the nipples intact)

Nipple-sparing mastectomies allow for more natural-looking breasts if the patient chooses to have a breast reconstruction surgery. However, total mastectomies are more effective in reducing breast cancer risks as more breast tissue is removed. Still, even in total mastectomies, it is impossible to completely eliminate the risks of breast cancer as not all the breast tissue can be removed. Sometimes, some breast tissue can be found in the chest wall, armpit, above the collarbone, and even in some women's abdomen. The remaining breast cells that were not removed can still become cancerous in the future.

Bilateral prophylactic mastectomies can reduce breast cancer risks by at least 95% in women with a disease-causing mutation in either the BRCA1 gene or the BRCA2 gene and up to 90% in women with a strong family history of breast cancer.

However, some things should be considered before getting a bilateral prophylactic mastectomy. Besides risks such as infection and bleeding at the surgery site, the most common effects of such a surgery are primarily psychological and emotional. Removing a breast or both breasts may cause emotional distress due to the change in body appearance. As breasts are associated with femininity, one may struggle with self-confidence. It may also affect one’s sexual experiences as most mastectomies result in the loss of nipple sensation, which may hinder sexual arousal and affect sexual relationships.

Women who are already diagnosed with breast cancer in one breast can choose to have a contralateral prophylactic mastectomy to remove the other breast (that does not have any cancer) as a risk-reducing method to lower the chances of getting a second breast cancer. However, this method is usually only recommended to those with other important risk factors, such as a disease-causing mutation in either the BRCA gene or a strong family history of breast cancer. Women who do not have these risk factors are not often encouraged to get a contralateral prophylactic mastectomy as the risks of getting a second breast cancer for these women are relatively small. The benefits of getting a contralateral prophylactic mastectomy for this group of women are unclear as there are other effective non-invasive methods, such as using risk-reducing drugs and going for more frequent screenings.

A prophylactic oophorectomy involves the removal of both ovaries (the organ that stores and releases eggs for reproduction) and their connecting fallopian tubes. As ovaries are the body’s primary producers of estrogen and estrogen fuels the growth of certain breast cancer cells, the removal of ovaries can reduce the risks of breast cancer by 50%, as studies show. A prophylactic oophorectomy can also reduce the chances of getting ovarian cancer by approximately 90%. As such, women with a BRCA1 or BRCA2 mutation may be recommended to get a prophylactic oophorectomy as they are also at a high risk of getting ovarian cancer.

However, this surgery does come with some side effects. As the removal of ovaries causes a sudden drop in estrogen, it induces early menopause in premenopausal women. This brings an onset of menopause symptoms. This includes hot flashes, insomnia, vaginal dryness, loss of bone density, anxiety, and depression. Long-term effects include decreased sex drive, vaginal dryness, and decreased bone density. As such, it is important to communicate with your healthcare provider and discuss the benefits versus limitations of such surgery to reduce breast cancer risk.

Determining whether or not preventive surgery is beneficial for someone is technically impossible to predict in advance. There are cases where women with a BRCA mutation or strong family history of breast cancer do not develop breast cancer in their lifetime. Getting such a surgery may not necessarily add more years to their life compared to other strategies, or taking no action at all. Additionally, undergoing preventive surgery does not guarantee full prevention of breast cancer as low risk does not equate to no risk. However, there are many women who have benefited from this risk-reducing method. Therefore, it is advisable to seek medical advice to assess your risk and explore all available options to make an informed decision on whether preventive surgery is the best course of action for you. Regardless of the decision you make, you are taking control of your health and future, and that is a courageous act.