Considering prophylactic mastectomy? An expert answers your questions

Prophylactic mastectomy is a preventative procedure that aims to lower the possibility of breast cancer developing in those prone to it. This is done by removing one or both breasts and is often complemented by reconstructive surgery to restore the appearance of the natural breasts. Those with a genetic predisposition to breast cancer have many factors to consider when deciding if they should opt for this potentially life-saving procedure. In today´s article, renowned consultant oncoplastic breast surgeon Mr Hazem Khout expertly explains the need-to-know information about prophylactic mastectomy surgery.

What is a prophylactic mastectomy?

Prophylactic mastectomy is a procedure where the breast tissue is removed without having a pathology in the breast itself, so without the diagnosis of any breast cancer. The breast can be removed to reduce the risk of having any cancer developing in the future.

Who should consider a prophylactic mastectomy?

Prophylactic mastectomy is a preventative procedure and ladies considering undergoing it generally fall into one of three categories:

• those who have already been diagnosed with cancer in one breast
• those who have been diagnosed with breast cancer who also have a genetic predisposition to developing breast cancer
• those without a cancer diagnosis but with a genetic predisposition to developing breast cancer

Ladies who have already been diagnosed with cancer in one breast may wish to have a prophylactic mastectomy of the non-cancerous, healthy breast as well as the removal of the cancerous breast to prevent the cancer from returning. Removal of both breast tissues is known as a bilateral mastectomy.

Additionally, ladies diagnosed with breast cancer who are later found to have gene mutations that give them a higher risk of developing breast cancer may also request a bilateral mastectomy. These mutations, such as BRCA1 or BRCA2 increase a woman’s likelihood of developing breast cancer.

Finally, ladies who do not have a cancer diagnosis but who are aware of their genetic predisposition to developing breast cancer may also consider a bilateral mastectomy. Despite not having any cancer at the time of the procedure, this surgery will reduce the patient’s risk of developing breast cancer in the future.

Is it a worthwhile procedure?

For patients who have been diagnosed with breast cancer, the majority of the time there is no benefit of having contralateral prophylactic mastectomy (removal of the healthy, non-cancerous breast).

However, it is important to note that all patients who have been diagnosed with breast cancer, including those with the associated gene problem, should discuss their individual case and the possible benefit of the procedure with their surgeon. The success of the surgery depends on a number of factors including the patient’s age and their lifelong risk of developing further breast cancer. Therefore, the possible benefits of prophylactic mastectomy should be determined on a case-by-case basis.

The third group, those who have not been diagnosed with cancer but have been diagnosed as having a genetic disorder that gives them a higher risk of breast cancer, may well benefit from having a bilateral mastectomy. The success of the procedure depends on the age that the patient is diagnosed with the genetic disorder as well as other risk factors. These can be assessed in clinic to further determine both the patient’s lifelong risk of developing breast cancer and also the impact of the surgery upon this.

Do patients ever regret opting for a prophylactic mastectomy?

As part of the patient’s decision-making process, we insist on having psychological input to ensure the patient makes an informed decision, helping to minimise any regrets afterwards. I think good preparation before the surgery and taking the time to understand the risks and the benefits of having a prophylactic mastectomy is the best way to move forward.

At what age can women opt for a prophylactic mastectomy?

A good consultation to quantify the benefits of the procedure for the individual patient is essential. The age at which a woman should consider a prophylactic mastectomy depends on their age at diagnosis and their plans relating to family. Some genetic disorders such as BRCA1 and BRCA2 also increase the risk of having ovarian cancer. In some cases therefore, the timing between undergoing an oophorectomy (surgery to remove the ovaries) and a mastectomy is also important and requires liaising between the patient, the breast surgeon and gynaecological surgeon.

Does the procedure differ for men and women?

There is little evidence that prophylactic mastectomies in men actually reduce their risk of developing breast cancer. However, some men do opt for the surgery. When they do so, the majority don´t ask for reconstruction so the procedure is a simple mastectomy. The majority also do not request nipple reconstruction or tattooing to restore the appearance of the chest, but this is available if the patient requests it. In general, more women come forward for prophylactic mastectomies, especially with gene disorders, compared to men.

What is the average success rate for prophylactic mastectomy?

Good preparation before surgery is important to understand the pros and cons. Having a prophylactic mastectomy, with or without removing the nipple, carries anything between a ninety and ninety five chance of reducing breast cancer risk.

It is important to remember that this percentage is based on the patient’s individual lifelong risk. If the patient’s lifelong risk is eighty per cent, for example, that would be a ninety per cent reduction of that risk number. Therefore, the procedure has a very high success rate in reducing the risk of developing breast cancer when it is indicated in the patient.

In terms of complications, as in any operation, informed consent between the patient and the consultant surgeon is very important to understand the pros and cons. There are also many other options to consider before undergoing surgery. For patients with a genetic predisposition but without cancer, the decision is based on the fear of developing a future cancer and therefore I think a very good consultation is absolutely essential to reduce that fear so that the patient can make the decision without pressure.

If you are considering a prophylactic mastectomy and would like more information, you can book a consultation with Mr Khout by visiting his Top Doctors profile.