Should I or shouldn’t I?
As a breast cancer surgeon, I am
often asked by patients who want to treat their cancer aggressively with a mastectomy if they should also remove their healthy breast.
Studies have shown that choosing to have a double mastectomy has become an increasing trend among women as evidenced by a study showing that between the years of 2002 and 2012 the rates of a double mastectomy tripled. The surprising fact is that this trend occurred before 2013, which is the year of actress Angelina Jolie’s decision to have a double mastectomy as a preventative measure after learning she carried a mutated BRCA gene. Her announcement of her decision was widely covered in the media.
Unfortunately, when helping a woman with breast cancer make the decision that is right for her, there is no way to know whether or not she will develop cancer in her other breast in the future. For that reason, women often consider removing the second breast in order to alleviate anxiety over that possibility. Many women believe that taking an aggressive surgical approach will improve their long-term survival.
The reality, however, is that research has shown that while it is appropriate for certain high-risk groups, most patients do not benefit from removing the non-affected breast – referred to as contralateral prophylactic mastectomy (CPM).
As breast surgeons, we also have learned that the likelihood of having complications after surgery — such as infection, bleeding, the need to return for more surgery, loss of the reconstruction, or chronic pain — is increased when two mastectomies are performed instead of one. This can hurt a patient’s long- term prognosis if other treatments that are needed to treat the breast cancer, such as chemotherapy or radiation, are delayed.
There has been much controversy over the topic, especially among physicians, patients and breast cancer advocates — so much so that the American Society of Breast Surgeons last year released a position statement with recommendations concerning the use of contralateral prophylactic mastectomy to assist them in making an informed choice.
The Society believes that a final treatment plan for the patient must be based on a close analysis of the individual’s perceived risk and fear of recurrence and anxiety of annual screenings and possible additional diagnostic procedures. Also the uncertainty of her emotional response to mastectomy in terms of quality of life and self-image and the potential variability of cosmetic surgical results from reconstruction should be considered..
With that said, there are times when a woman should consider CPM. For example, if a woman has tested positive for carrying the BRCA gene mutation, her risk of developing breast cancer again in her lifetime is high enough that removing the other breast should at least be considered. There also are situations for which a double mastectomy can be considered, such as when a woman may have a very strong family history for breast cancer without there being a known BRCA gene mutation, or a woman has received chest radiation for treatment of other cancers such as Hodgkin’s lymphoma.
As breast surgeons, we are challenged in addressing our patients’ fears of cancer recurrence — a key reason for their selection of CPM — while making sure all options are considered and all information is provided to the patient.
When breast cancer returns, it can either recur in the breast that had cancer originally or elsewhere in the body. Removing the second breast does not lower this risk. What helps to reduce this risk is medicine — such as chemotherapy or anti-hormone therapy — that will be given.
Just as we recommend that women have an honest discussion with their physicians about when to begin breast screening, the key to decision-making concerning CPM is much the same. Ultimately, it is our role to provide our patients with information that will allow them to make a decision that is right for them.
Dr. Holly Mason is Section Chief, Breast Surgery Division of Surgical Oncology, Baystate Medical Center Baystate Regional Cancer Program. She is one of several Baystate professionals who address issues related to cancer in this space on a rotating basis each month.