Prophylactic Mastectomy in Carriers of BRCA Mutation
Prophylactic total or simple mastectomy for patients at high risk of breast cancer is a difficult issue in that it involves the determination of risk in an individual patient, a separate determination of what level of risk is high enough to justify the extreme choice of prophylactic mastectomy, and assurance from scientific studies in the medical literature that this procedure does result in a reduction of breast cancer occurrence. Mastectomies that do not remove all possible breast tissue, for example subcutaneous mastectomy or simple mastectomy may leave behind enough breast tissue to sufficiently reduce the risk of breast cancer in BRCA positive women. Often the tail of the breast that goes into the armpit and contains 5% of all breast tissue may be left behind. It is, however, generally assumed that the high risks of breast cancer in women with BRCA positivity justifies mastectomy and other risk reduction measures. Even the usually parsimonious European EMO guideline of 2011 says: “It is the most effective strategy available for risk reduction of breast cancer in mutation carriers [III, B], although no benefit in survival has been demonstrated and many women do not find this strategy acceptable for cosmetic reasons. Contralateral prophylactic mastectomy is an option to consider in those BRCA mutation carriers with early breast cancer undergoing unilateral mastectomy [III, B].” Other guidelines echo these recommendations. Other options for risk reduction include hormonal prophylaxis with tamoxifen or aromatase inhibitors and/or oophorectomy as well as intensive surveillance.
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