Wednesday, January 28, 2009

Prophylactic Mastectomy

The article recently published online in the journal Cancer (due in print in their March issue) looks at the risks factors that increase the likelihood of a woman being diagnosed with breast cancer in her “other” breast after being diagnosed with breast cancer.

The article was done at MD Anderson Cancer Center in Houston.  It looked at 542 women with breast cancer diagnosed in one breast (unilateral breast).  All of the women decided to have this and the other breast (contralateral prophylactic mastectomy).

The researchers identified are three factors that increases the chance of cancer in the other breast.  These three factors are:

  • having more than one tumor in the same breast at the time of initial diagnosis of breast cancer
  • having invasive lobular breast cancer, which begins in the milk-producing glands called lobules rather than in the milk ducts, and then invades surrounding tissues
  • having a high score in the so-called Gail model that calculates breast cancer risk and considers things such as age at first menstrual period, age when first child was born and whether close relatives like mother or sister had the disease.

 

Factors that did not help determine the risk of developing a future cancer in the other breasts included:  race and hormone receptor status of the cancer.

The study did not focus on whether mutations in the genes called BRCA1 and BRCA2 that raise the risk of breast cancer also raised the risk of having cancer later develop in the initially unaffected breast.  Often women with these mutations or a strong family history of breast cancer get preventive mastectomies even before any tumor has developed in either breast.

Having a breast surgically removed when you have breast cancer in the other breast has long been an option, but there appears to be a renewed interest among women (and their doctors). 

When I was a plastic surgery resident and early in my practice, prophylactic mastectomies were an accepted way to deal with the “high risk” of breast cancer.   We often did bilateral prophylactic mastectomies.   I found my copy of the American Society of Plastic and Reconstructive Surgeons Position Paper on Prophylactic Mastectomy (recommended criteria for third-party payer coverage) from 1994.  Here are the indications listed:

Prophylactic mastectomy is recommended for either the treatment of breast symptoms or to prevent cancer from developing in the breast.  Accepted indications for mastectomy include the presence of biopsy-proven tissue of uncertain behavior, the presence of microscopic foci of lobular carcinoma or ductal carcinoma in-situ, and both personal and family histories of breast cancer.  In these high-risk patients, statistics support prophylactic mastectomy.  Fibrocystic mastopathy may generate enough fibrosis to render mammography useless for cancer detection.

Other indications for mastectomy and reconstruction include injected silicone mastopathy, a history of multiple breast biopsies, cancerphobia, progressive fibrocystic mastopathy preventing adequate examination, and refractory mastodynia.

Definite indications for prophylactic mastectomy include lobular or ductal carcinoma in-situ; proliferative atypical dysplasi; severe dysplasia; personal history of breast cancer; personal history of breast cancer in opposite breast; one first-order relative with bilateral, premenopausal breast cancer; two first-order relatives with premenopausal breast cancer; desmoid tumor of the breast or giant fibroadenoma; cystosarcoma phylloides; significant virginal hypertrophy, and post-injection silicone mastopathy.

Two or more of the following conditions also represent indications for prophylactic mastectomy:  one first-order relative with premenopausal breast cancer, one first-order relative with postmenopausal breast cancer, obscured mammograms due to fibrosis, history of multiple breast biopsies, and refractory fibrocystic mastodynia.

 

It is nice to have this new study as it reinforces many of the reasons I was taught, but it also “refines” the reasons.  However, this is not a new treatment.  It is a “resurgence” of an old treatment.  It fell out of favor because it became difficult to get insurance to pay for it.

 

 

REFERENCE

Predictors of Contralateral Breast Cancer in Patients with Unilateral Breast Cancer undergoing Contralateral Prophylactic Mastectomy; CANCER Print Issue Date: March 1, 2009; Published Online: January 26, 2009; DOI: 10.002/cncr.24129 (abstract); Min Yi, Funda Meric-Bernstam, Lavinia P. Middleton, Banu K. Arun, Isabelle Bedrosian, Gildy V. Babiera, Rosa F. Hwang, Henry M. Kuerer, Wei Yang, and Kelly K. Hunt.

7 comments:

Buckeye Surgeon said...

Thanks Ramona. I read that article last week. Pretty good stuff in it. I've also found that with women with large, pendulous breasts, it can be difficult to get a good cosmetic outcome with unilateral reconstruction. Is this a justification for prophylactic bilat recon, in your experience (in terms of insurance compensation)?

Helen said...

I spotted this article in Cancer but never got round to reading it - thanks for covering the topic so well!

Lana G. Nelson, DO said...

Great review of the need and consideration of prophylactic mastectomy. It seems as though 75% of our research is devoted to re-evaluating questions we have already answered, but all to frequently we find we got the answer wrong the first time. It is re-assuring that what we have believed to be true and what we have practice does not always change in this incredibly dynamic field of medicine.

rlbates said...

Buckeye, I don't think that a large, pendulous breast in and of itself is a good enough reason for a bilat prophylatic mastectomy/reconstruction. Insurance will allow a reduction or lift of the non-cancer breast so that it can more closely match the reconstructed one.

Helen and Dr Nelson, thanks.

Anonymous said...

Thank you for your insight. I'm always searching for info on prophylactic mastectomy. I'm BRCA1 positive with a very strong family history of breast cancer (my mother died at 45!). I'm having prophylactic surgery next month. It's scary and liberating all in one...

Anonymous said...

I am very similar to "anonymous"... I am BRCA1 positive, mother died of breast cancer at 44, sister diagnosed at 25 (also BRCA1 pos), aunt died of ovarian cancer at 50, her daugher has breast cancer at 46(BRCA1 +) and another aunt now has breast cancer. Am have prophylactic mastectomy soon. Very scary but obvously needs to be done.

rlbates said...

Best wishes to both Anons. Take care.