The last decade has seen a steady rise (300% increase) in the number of individuals who are opting to undergo a contralateral prophylactic mastectomy (CPM) as a means of reducing their risk of developing a new breast cancer in their opposite breast.
(Listen to an audio discussion on this trend)
Why Women Choose To Remove Both Breasts After A Breast Cancer Diagnosis:
This procedure is most compelling to those patients with an increased risk of developing a contralateral breast cancer (i.e. BRCA 1/2 gene mutations, strong family history of breast cancer, prior exposure of radiation to the breast, etc.), although CPM will significantly reduce the risk of developing a contralateral breast cancer in all patients (there is always a small amount of residual breast tissue remaining even after a mastectomy, and tumors can develop in this tissue.)
**Read my post on who should get BRCA gene mutation testing to assess breast cancer risk**
Even in women who have none of the above risk factors placing them at an increased risk of developing a contralateral breast cancer, many express that they simply want to avoid having to go through repeat imaging studies (and possible biopsies), and subjecting themselves to the fear of recurrence and/or discomfort of these procedures. Others feel that having a CPM will leave them with more symmetry (particularly if they have larger breasts) and may help them obtain a better cosmetic outcome if they choose to have reconstruction.
What Percent Of Women Undergoing CPM Have BRCA mutations or Other High-Risk Factors For Developing A Cancer In The Opposite Breast?
In one recent study, investigators reported that only 13% of women who underwent CPM had BRCA mutations or previous radiation exposure — the 2 factors that are associated with an increased risk for contralateral breast cancer and are accepted indications for the procedure.
There Is No ‘Right’ or ‘Wrong’ Decision Regarding CPM…But First Know The Facts:
As an oncologist, I feel that the decision to undergo CPM is one that should be made with a complete understanding of the data. Whatever decision feels right to the patient is valid and must be respected. Here are some facts:
What is the risk of developing a contralateral breast cancer in an intact breast?
- Annual rate of developing a contralateral breast cancer is 0.1-0.3% (0.2-0.7% annual rate for women with hormone receptor-negative first tumors).
Does adjuvant hormonal therapy reduce the risk of developing a contralateral breast cancer?
- Yes. The data indicate that the annual risk of developing a contralateral breast cancer is reduced from 0.5% (without hormonal therapy) to 0.2% (with hormonal therapy).
Does CPM reduce the risk of dying from a new contralateral breast cancer?
- Based on the available data (which are limited by the small number of patients who develop contralateral breast cancer), there is “insufficient evidence that CPM improves survival.”
- Nevertheless, retrospective studies have reported an improvement in overall survival (5%) with CPM among women at high-risk (i.e. young age, estrogen receptor-negative first tumors) of developing a contralateral breast cancer.
Do women remain satisfied with their decision to undergo CPM years later?
- The majority of women (approximately 85%) continue to have an overall high-degree of satisfaction regarding their decision to undergo CPM (10 year follow-up).
- The majority of women experienced no change or favorable effects in self-esteem (83%), level of stress in life (83%), and emotional stability (88%).
- A large minority (33%) described a negative impact on their appearance, feelings of femininity (26%) and effect on sexual relations (23%).
- Among women who underwent CPM with breast reconstruction, the majority (90%) would choose the same reconstructive procedure again.
What is the risk of complications following CPM with breast reconstruction?
- Surgical complications and rates of additional surgery in breast reconstruction range from 10-50%.
- Implant reconstructions are associated with a higher risk of reoperations than tissue transfer reconstructions.
- Reoperations are performed for various reasons: postoperative complications (i.e. infections, hematomas etc.), implant-related issues, aesthetic concerns (non-implant related), etc. Implant contracture is the most common indication for reoperation.
- Most reoperations occur within the first year of the reconstruction.
- Chronic pain (persisting at least 2 years) after mastectomy and reconstruction is a frequent problem, affecting up to 70% of women. This can negatively impact on sleep (in 36% patients) and daily activities (in 22%). 10-15% of women can experience severe, long-lasting pain.
**No Easy Choices on Breast Reconstruction (New York Times, May 20, 2013)**
In summary:
Deciding whether or not to undergo a CPM at the stressful time of diagnosis can be overwhelming for many patients who are just beginning to cope with the reality of their cancer diagnosis. Whenever possible, the cancer care team members need to express to their patients that they have time to think about their surgical management and obtain second opinions. They need to hear the facts and have time to think about their options. Whatever decision they make regarding CPM, the oncology team should support.
Additional Resources:
- National Cancer Institute (Fact sheet on preventive mastectomy)
- Susan G. Komen (Information on preventive mastectomy)
- Breastcancer.org (Information on prophylactic mastectomy)
- Breastfree.org (“A non-profit website for women who want to learn more about living breast-free. Here, you’ll find the information you need to select breast forms, bras, and swimsuits. You’ll find advice about creative ways to look good and feel great about yourself. And you’ll find support from women who have chosen not to reconstruct and want to share their stories with you.”)
