Diseases

Existing data suggest that preventive mastectomy may significantly reduce (by about 90 percent) the chance of developing breast cancer in moderate- and high-risk women. However, no one can be certain that this procedure will protect an individual woman from breast cancer. Breast tissue is widely distributed on the chest wall, and can sometimes be found in the armpit, above the collarbone, and as far down as the abdomen. Because it is impossible for a surgeon to remove all breast tissue, breast cancer can still develop in the small amount of remaining tissue

Doctors do not always agree on the most effective way to manage the care of women who have a strong family history of breast cancer and/or have other risk factors for the disease. Some doctors may advise very close monitoring (periodic mammograms, regular checkups that include a clinical breast examination performed by a health care professional, and monthly breast self-examinations) to increase the chance of detecting breast cancer at an early stage. Some doctors may recommend preventive mastectomy, while others may prescribe tamoxifen or raloxifene, medications that have been shown to decrease the chances of getting breast cancer in women at high risk of the disease. (More information about tamoxifen and raloxifene is available in the National Cancer Institute's (NCI) fact sheets, Tamoxifen: Questions and Answers, which can be found at http://www.cancer.gov/cancertopics/factsheet/Therapy/tamoxifen on the Internet, and The Study of Tamoxifen and Raloxifene (STAR): Questions and Answers, which can be found at http://www.cancer.gov/newscenter/pressreleases/STARresultsQandA on the Internet.) Doctors may also encourage women at high risk to limit their consumption of alcohol, eat a low-fat diet, engage in regular exercise, and avoid menopausal hormone use. Although these lifestyle recommendations make sense and are part of an overall healthy way of living, we do not yet have clear and convincing proof that they specifically reduce the risk of developing breast cancer.

Like any other surgery, complications such as bleeding or infection can occur. Preventive mastectomy is irreversible and can have psychological effects on a woman due to a change in body image and loss of normal breast functions. A woman should discuss her feelings about mastectomy, as well as alternatives to surgery, with her health care providers. Some women obtain a second medical opinion to help with the decision.

Breast reconstruction is a plastic surgery procedure in which the shape of the breast is rebuilt. Many women who choose to have preventive mastectomy also decide to have breast reconstruction, either at the time of the mastectomy or at some later time. Before performing breast reconstruction, the plastic surgeon carefully examines the breasts and discusses the reconstruction options. In one type of reconstructive procedure, the surgeon inserts an implant (a balloon-like device filled with saline or silicone) under the skin and the chest muscles. Another procedure, called tissue flap reconstruction, uses skin, fat, and muscle from the woman's abdomen, back, or buttocks to create the breast shape. The surgeon will discuss with the patient any limitations on exercise or arm motion that might result from these operations.

Preventive mastectomy (also called prophylactic or risk-reducing mastectomy ) is the surgical removal of one or both breasts in an effort to prevent or reduce the risk of breast cancer. Preventive mastectomy involves one of two basic procedures: total mastectomy and subcutaneous mastectomy. In a total mastectomy, the doctor removes the entire breast and nipple. In a subcutaneous mastectomy, the doctor removes the breast tissue but leaves the nipple intact. Doctors most often recommend a total mastectomy because it removes more tissue than a subcutaneous mastectomy. A total mastectomy provides the greatest protection against cancer developing in any remaining breast tissue.

Women who have reconstructive surgery are monitored carefully to detect and treat complications, such as infection, movement of the implant, or contracture (the formation of a firm, fibrous shell or scar tissue around the implant caused by the body's reaction to the implant). Women who have tissue flap reconstruction may want to ask their surgeon about physical therapy, which can help them adjust to limitations in activity and exercise after surgery. Routine screening for breast cancer is also part of the postoperative follow-up, because the risk of cancer cannot be completely eliminated. When women with breast implants have mammograms, they should tell the radiology technician about the implant. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant. However, women who have had reconstructive surgery on both breasts should ask their doctors whether mammograms are still necessary. (More information about mammograms can be found in the NCI fact sheet, Screening Mammograms: Questions and Answers, at http://www.cancer.gov/cancertopics/factsheet/Detection/screening-mammograms on the Internet.)

The U.S. Food and Drug Administration (FDA) regulates the use of breast implants and can supply detailed information about these devices. To listen to recorded information or request free printed material on breast implants, consumers can contact the FDA Center for Devices and Radiological Health (CDRH) at: U.S. Foods and Drug Administration Consumer Staff Center for Devices and Radiological Health Office of Device Evaluation 10903 New Hampshire Avenue WO66-1676 Silver Spring, MD 20993-0002 Telephone: 1-888-INFO-FDA (1-888-463-6332), toll-free 301-827-3990 (Call between 8:00 a.m. and 4:30 p.m., Eastern Standard Time, for either number.) E-mail: [email protected] Web site: http://www.fda.gov/cdrh/consumer/index.html http://www.fda.gov/cdrh/breastimplants (Breast Implants Home Page)

Women who are at high risk of developing breast cancer may consider preventive mastectomy as a way of decreasing their risk of this disease. Some of the factors that increase a woman's chance of developing breast cancer include the following:

• Previous breast cancer -- A woman who has had cancer in one breast is more likely to develop a new cancer in the opposite breast. Occasionally, such women may consider preventive mastectomy to decrease the chance of developing a new breast cancer.
• Family history of breast cancer -- Preventive mastectomy may be an option for a woman whose mother, sister, or daughter had breast cancer, especially if they were diagnosed before age 50. If multiple family members have breast or ovarian cancer, then a woman's risk of breast cancer may be even higher.
• Breast cancer-causing gene alteration - A woman who tests positive for changes, or mutations, in certain genes that increase the risk of breast cancer (such as the BRCA1 or BRCA2 gene) may consider preventive mastectomy.
• Lobular carcinoma in situ - Preventive mastectomy is sometimes considered for a woman with lobular carcinoma in situ, a condition that increases the risk of developing breast cancer in either breast.
• Diffuse and indeterminate breast microcalcifications or dense breasts - Rarely, preventive mastectomy may be considered for a woman who has diffuse and indeterminate breast microcalcifications (tiny deposits of calcium in the breast) or for a woman whose breast tissue is very dense. Dense breast tissue is linked to an increased risk of breast cancer and also makes diagnosing breast abnormalities difficult. Multiple biopsies, which may be necessary for diagnosing abnormalities in dense breasts, cause scarring and further complicate examination of the breast tissue, by both physical examination and mammography.
• Radiation therapy - A woman who had radiation therapy to the chest (including the breasts) before age 30 is at an increased risk of developing breast cancer throughout her life. This includes women treated for Hodgkin's lymphoma.

It is important for a woman who is considering preventive mastectomy to talk with a doctor about her risk of developing breast cancer (with or without a mastectomy), the surgical procedure, and potential complications. All women are different, so preventive mastectomy should be considered in the context of each woman's unique risk factors and her level of concern.