When is Double Mastectomy Appropriate?

07 Apr 2016 in

Most women have heard of mastectomy, which is commonly performed to treat or reduce risk for breast cancer. In the age of improved cancer treatment, improved screening tools, and emphasis on long-term survival and benefits, it is important to question exactly when and for who a double mastectomy is beneficial.

Risk-Reducing Prophylactic Mastectomy

Prophylactic mastectomy is the most commonly performed preventive surgery in women at very high risk for breast cancer. Prophylactic mastectomy involves the surgical removal of virtually all breast tissue. Some high-risk women with no previous breast cancer diagnoses may consider this option. Some women previously diagnosed with breast cancer may also consider prophylactic mastectomy in their unaffected breast to reduce risk of recurrence.

Prophylactic mastectomy should only be performed in women with certain risk factors for breast cancer. In women with no previous diagnosis, these risk factors include:

  • Strong family history of breast cancer, such as multiple first-degree relatives diagnosed before the age of 50.
  • Pathogenic mutations to certain breast cancer-related genes, such as BRCA1, BRCA2 and
  • Certain noncancerous conditions, like atypical hyperplasia and lobular carcinoma in situ.

These risk factors also apply to women previously diagnosed with breast cancer who are considering prophylactic mastectomy to reduce risk of recurrence. Management of these patients should also consider the following factors:

  • Whether surveillance and screening would be especially difficult.
  • Whether symmetry between breasts would be difficult to achieve during reconstructive surgery.

Cancer Treatment: Mastectomy vs. Alternatives

Recent research suggests that many women with early stage breast cancers can benefit from breast conserving surgery with radiation therapy compared to mastectomy. During breast conserving surgery, also known as lumpectomy, only the tumor and surrounding tissues is removed. This is followed by radiation therapy to kill any remaining cancer cells.

Data from the Netherlands Cancer Registry, presented at the 2015 San Antonio Breast Cancer Symposium (SABCS), showed benefits to breast conserving surgery with radiation therapy in women with small cancers with no lymph node involvement. In a study including more than 37,000 patients with early stage cancers, researchers determined that 10-year overall survival rates and distant disease-free survival rates were better in patients who chose breast conserving surgery and radiation therapy over mastectomy.

Additionally, breast conserving surgery and radiation therapy is as cost-effective, if not more cost-effective, than mastectomy and breast reconstruction, according to researchers from the University of Texas MD Anderson Cancer Center. At the 2015 SABCS, they presented data showing that women who underwent mastectomy and reconstruction were around twice as likely to suffer complications as women who underwent breast conserving surgery and whole breast radiation therapy. These complications result in excess costs.

This data should lead us to ask ourselves, when is mastectomy justified in 2016 and beyond? Physicians should consider potential benefits, risks and costs to both patients as well as society when making treatment recommendations to women with early stage breast cancers.

The Breast Cancer Patient Education Act

In other recent developments related to mastectomy, Congress passed the Breast Cancer Patient Education Act (BCPEA) in late 2015. The intent of this legislation is to raise awareness regarding certain rights afforded to breast cancer patients. Since 1998, the Women’s Health Care and Cancer Rights Act has required health plans that provide coverage for breast cancer care to include coverage for mastectomy. However, many patients may be unaware of this requirement.

Less than one-half of patients who undergo mastectomy subsequently undergo breast reconstruction, according to research published August 2014 in JAMA SurgeryWhile some patients likely made a well-informed decision against breast reconstruction, researchers concluded that many patients are not properly educated regarding the safety of breast implants and post-treatment effects of breast reconstruction.

The BCPEA requires the Department of Health and Human Services to establish an educational campaign regarding the availability of breast reconstruction. This should help to spread information about insurance coverage requirements to breast cancer patients.

The Future of Mastectomy

While mastectomy for risk reduction and as treatment is appropriate for some women, recent developments point toward a future where we rely more on alternatives. For instance, as the Netherlands Cancer Registry data shows, breast conserving surgery with radiation therapy can be used in place of mastectomy in many women with early stage breast cancers. Additionally, developments in our knowledge of breast cancer biology has led to clinical tools that can help us identify whether patients are likely to benefit from certain therapies.

Shared decision-making among breast cancer patients and their care teams is only possible when patients are well-informed and actively involved in treatment planning. At Breastlink, we are committed to patient education, as well as to maintain up-to-date knowledge ourselves, to ensure that patients are equipped to make the best possible treatment decisions for their personal health.

For more information, please contact us.

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