Bilateral mastectomy for early breast cancer

So, the unthinkable has happened – the biopsy of the lump you felt in your breast has confirmed the presence of cancer… hundreds of questions are going through your mind, foremost of which is how quickly and completely can you have it removed. You, or indeed your surgeon, may be inclined to rush into theatre the following day – please do not do this! Any tumour in your breast has almost certainly been growing there for some time (many months at least), so take a few days or even 1-2 weeks to make appropriate informed decisions, which will impact you for the rest of your life – don’t rush!

One of the foremost decisions facing women with newly-diagnosed early stage breast cancer is how radical should their surgery be; including the role of bilateral (“double”) mastectomy, also known as contralateral prophylactic mastectomy (CPM) – ie: removing the unaffected breast as a precaution. If possible, discuss your options with your surgeon and an oncologist as a minimum, or a multi-disciplinary team – each person and her situation is different.

Over the last 10 years women undergoing bilateral mastectomy for early stage breast cancer has increased 5-10 times in the USA, with more than 30% of younger women opting for this surgery. There are certain situations where this is of importance, such as familial breast cancer (as in the case of Angelina Jolie), lobular carcinoma, and high-risk situations (such as previous radiotherapy to the chest). Some women opt for bilateral mastectomy for personal aesthetic reasons, often related to reconstruction and symmetry. The majority, however, choose this out of a mistaken belief that it reduces breast cancer recurrence risk.

The complications of undergoing bilateral mastectomy are significantly increased over single mastectomy, and although the overall complication rates are low, include a higher risk of having blood transfusions, longer hospital stay, higher risk of re-operation, and higher risk of implant loss after reconstruction. Multiple studies, however, do not show any convincing benefit in terms of improved survival, nor of decreased relapse risk after undergoing CPM.

Most patients who have undergone breast cancer surgery will be referred to an oncology centre (sometimes prior to surgery) for an assessment for possible “adjuvant therapy.” This may include (amongst others) chemotherapy, and/or radiotherapy and/or hormonal therapy – these treatments are aimed at reducing future risk of cancer recurrence/spread by suppressing residual microscopic cancer cells left behind (anywhere in the body) post surgery. It is important to understand that these treatments protect the whole body, including your other breast. In addition, the rate of relapse of breast cancer in the other breast is very small (less than 0.5% per year) compared to other organs – one would hardly consider removing your lung or liver as a precaution against developing spread of breast cancer there in the future, so why your healthy breast?!

In summary, your decision as to whether to undergo bilateral mastectomy needs to be made after careful discussion with your surgeon and oncologist, on the understanding that:

• There is (except under special circumstances as mentioned above) no benefit in terms of reducing future cancer risk.

• There may be more side effects to the procedure.

• The need for adjuvant chemotherapy and/or hormone therapy and/or biological therapy (eg: Herceptin) will not be affected by the extent of surgery.

• You will still need to undergo regular follow-up visits to check for recurrence, regardless of the extent of surgery.

Do not rush into a decision regarding this, nor indeed any, aspect of your cancer treatment – take the time to explore your options and how they will impact your future risk and follow up on your road to recovery.

References:

1 JAMA, Sept3, 2014 – Vol312, No.9.

2 JAMA Surgery, June 2014 – Vol 149, No.6.

3 J Clin Oncol 10 Sept 2014 – Vol32(26), Supp, Abstract 62.

Written by Dr G.B McMichael.

Leave a Reply

Your email address will not be published. Required fields are marked *