When is the right time to undergo risk reducing surgery?

In the previous issue of Buddies For Life magazine we looked at several factors that increased the risk of developing breast cancer. This article will explore the various factors that have to be taken into account when deciding ‘the right time’ to undergo risk reducing surgery.  

The decision to undergo a risk reducing mastectomy at the time of opposite side breast cancer management is difficult particularly when a women is at her most vulnerable (post diagnosis). Careful consideration to this decision should be made by the patient and her family and not by the treating physician. However, multi-disciplinary unit guidance is advisable, as well as repeated appointments with the onco-psychologist in the unit. Should the patient be unsure of this decision, it is always advisable to delay the decision and surgery on the other breast.

A study from our unit looking at risk of disease in the opposite breast in women with a unilateral breast carcinoma, who elected to undergo an opposite side risk reduction showed the following results:

Over the 10-year study period 412 patients underwent bilateral mastectomy following an initial diagnosis of unilateral breast cancer. Records were identified relating to 382 patients (30 excluded due to lack of data). A further 24 had a contralateral cancer (n=10), high-risk lesion (n=6) or recurrent cancer (n=8) diagnosed prior to definitive surgery, and they were also excluded. The remaining 358 patients had a unilateral invasive breast cancer, or ductal carcinoma in situ (DCIS) excised through mastectomy with a contralateral prophylactic mastectomy.

It may be feasible to assume that a percentage of these patients would develop breast cancer should they not have chosen to undergo risk reducing surgery.

In terms of decisions around bilateral risk reduction, there are no rules, but some guidelines are as follows:

1. Age of earliest diagnosed familial breast cancer may play a role in decision-making.

2. Post completion of family.

3. Sudden life – changing events, death of a family member and or close friend from breast cancer.

4. Advice from radiologist.

5. Repeated core biopsies.

6. Diagnosis of a high-risk lesion.

How much?

The premise when it comes to risk reduction is clearly more is better than less. Original studies on risk reduction surgery were based on subcutaneous mastectomies and this resulted in a substantial proportion of breast tissue being left, including the nipple areolar complex. Over time with the development of skin sparing mastectomy techniques, less and less breast tissue is left

The current item up for debate is the concept of nipple sparing mastectomies.

The nipple areolar complex is regarded as the signature of the breast or likened to the tip of a nose and has significant aesthetic impact and has both sexual and psychological importance due mainly to its nerve sensation (erectile ability, erogenous sensation). Emotive reasons for nipple sparing mastectomies (NSM) may negatively influence the ability to accurately assess the procedure.

The current gold standard when required to do a mastectomy and reconstruction, is a skin sparing mastectomy and immediate prosthesis or expander prosthesis reconstruction. This traditionally includes the removal of the nipple areolar complex to ensure clear surgical margins.

Looking at retrospective studies on patients undergoing skin-sparing mastectomies for invasive cancer or DCIS, the nipple is affected by tumour cells in 5%-10% of cases.

It is for this reason that the concept of nipple sparing mastectomies has been proposed.

There has been much controversy regarding the oncologic safety of NSM, as well as the introduction of a set of complications, such as nipple and areolar necrosis, that were not a concern previously with total mastectomy.

Complicating these issues is the data analysis; the lack of randomised control trials, no long term follow-up, and small isolated centre based retrospective audits.

Looking at nipple sparing mastectomies in the risk reduction setting is critical as prophylactic mastectomy has been the subject of major publications by many international groups. Its oncology benefit is undisputed in patients with a genetic mutation, and often questioned in other patients undergoing the procedure.

Immediate bilateral breast reconstruction by expander or definitive implant with skin flap preservation and retention of the nipple-areolar complex may constitute a positive radical issue for requesting and motivating patients at high genetic risk, managed by a multidisciplinary team to undergo this procedure.

The incidence of cancer in the retained nipple after risk-reducing mastectomy is documented at less than one per cent.

Technical problems with the procedure can be avoided by careful patient selection.

Reconstructive difficulties occur more frequently in patients who have large breasts or very ptotic breasts, and may require the use of mastopexy type skin sparing mastectomies. The nipple blood supply in these settings is often further compromised. Clearly the most significant concern is nipple viability followed by flap necrosis.

As with any procedure attention to careful patient selection and technical capability of the surgeon plays a role as well as understanding the learning curve associated with the procedure.

The lowest recurrence rates are seen in multi-disciplinary units that use intra-operative pathology after coring out the nipple to assess that the tissue is free of malignant or atypical cells.

Complications occurring are:

1. Partial necrosis of the nipple

with residual depigmentation.

2. Sloughing of the nipple areola complex.

3. Infection.

After dissection of all the breast tissue, the skin envelope with the areola is turned inside out and all milk ducts and any tissue beneath the areola are precisely dissected under the surgeon’s visual control. Intra-operative pathological assessment of this retro-areolar tissue next to the skin is performed using both imprint cytology and histology to decide whether the NA-skin can be preserved or not

Incisions vary from centre to centre with areola crossing, and radial incisions being the most commonly used.  Circumareolar/nipple-areola free graft, inframammary and crescentic mastopexy may also be used.

Immediate reconstruction can be performed with tissue expander placement or one stage implant latissimus dorsi muscle, transverse rectus abdominis muscle, or deep inferior epigastric perforator muscle flaps.

Long-term outcome

Recurrence risk

Clearly in patients undergoing risk reducing surgery with diverse indications such as confirmed BRCA 1 and 2, strong family history of breast cancer, atypical ductal hyperplasia, lobular carcinoma in situ and other risk lesions have extremely low recurrence rates irrespective of whichever technique is used. The reason for this is that the actual incidence of these patients developing breast cancer post mastectomy cannot be accurately quantified.

Aesthetic outcome

Studies looking at patient satisfaction with objective observer assessments are few. Important aspects to assess are appearance, symmetry, colour, position, and breast texture, as well as nipple sensation and arousal. Most studies are small, and most patients are satisfied with the appearance, symmetry, colour, position of the nipple and the breast texture. However, there is lower satisfaction amongst all patients with nipple sensation, most patients rating this as poor.

Long – term aesthetic outcome varies from study to study and is based on a multitude of factors such as weight gain and lifestyle habits.

Psychological outcome

Most patients, who have undergone the procedure, if they have been properly counseled, do not regret the decision at all. However, studies are few.

Conclusion

Risk reducing mastectomy is an important procedure that can, and should be discussed with women who consider themselves to be of high risk.

It should only be offered in multi-disciplinary units, after careful consideration is given to all the cons of the procedure and should never be offered as an emergency.

Opposite side risk reduction mastectomy, although on the increase, should be entirely a patient based decision, this decision should be made after extensive counselling, as the risk of contralateral disease is low.

MEET THE EXPERT

Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

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