Preventive mastectomy (or prophylactic mastectomy) is a procedure for removing the breast in order to prevent the development of cancer. Preventive mastectomy is performed in patients with a very high risk of developing breast cancer. Qualifying a patient for preventive mastectomy requires an individual analysis of the indications, potential benefits and risks associated with the surgery. Find out what are the indications for preventive mastectomy, how does preventive mastectomy work and what is the effectiveness of preventive mastectomy in the prevention of breast cancer.

Preventive mastectomy , otherwisepreventive mastectomy , gained media popularity thanks to Angelina Jolie, who underwent this surgery in 2013. The topics of breast cancer risk, the family history of this cancer, and the genetic burden associated with it have since become more widely known. In the meantime, the results of numerous scientific studies have been published, showing the effectiveness and validity of preventive mastectomy in specific groups of patients. Based on these data, in Poland, preventive mastectomy was included in the procedures financed by the National He alth Fund in 2022. What is preventive mastectomy and when is it justified?

Preventive mastectomy - what is it?

A preventive mastectomy is a surgical procedure involving the removal of one or both of the mammary glands (we are talking about a unilateral or bilateral mastectomy, respectively).

Preventive mastectomy is performed to prevent the development of breast cancer. Preventive mastectomy is designed to significantly reduce the risk of breast cancer in patients who are at a very high risk of developing this cancer.

A preventive mastectomy is performed after the factors that increase a patient's risk have been identified, before the cancer develops. Preventive mastectomy should not be confused with therapeutic mastectomy, performed when the patient is diagnosed with breast cancer.

Preventive mastectomy and the risk of developing breast cancer

Breast cancer is the most common of all malignant neoplasms in women. There are many factors that predispose to the development of breast cancer - older age,Obesity, early menstruation or late menopause are just some of them.

Prevention of breast cancer in the general population should include a he althy lifestyle, avoiding alcohol and tobacco products, maintaining a he althy body weight and regular physical activity.

Unfortunately, in some cases of breast cancer, factors that cannot be eliminated through lifestyle modification play a major role. We are talking about genetic-related breast cancer, which accounts for 5-10% of all cases of the disease.

Breast cancer resulting from a genetic burden occurs in several generations of women within one family. Cases of such breast cancer may occur in relatively younger women, and more often it affects both breasts (simultaneously or with some spacing). The best known genetic risk factors for breast cancer are mutations in the BRCA1 and BRCA2 genes, which also increase the risk of developing ovarian cancer.

The presence of breast cancer in the family, in particular cases of breast cancer occurrence before the age of 50, the multifocal or bilateral nature of the tumor, as well as the presence of ovarian cancer in a family member, is an indication for genetic testing. In Poland, the most frequently searched for mutations in the BRCA1 gene, and slightly less frequently - the BRCA2.

Based on the results of genetic tests as well as family history, the patient may be classified into a specific risk group for developing breast cancer. Preventive mastectomy is usually considered for patients who are at the highest risk of developing the disease. The current guidelines include all women with a confirmed BRCA1 or BRCA2 mutation in this group.

It's good to know that not all genes that increase the risk of breast cancer are well understood. Consequently, some BRCA1 or BRCA2 negative patients are nevertheless at the highest risk of developing breast cancer. These include women with a highly burdened family history.

The criteria include the occurrence of ≥3 breast cancer cases in the immediate family (1st and 2nd degree relatives), as well as coexisting breast cancer and ovarian cancer. It is believed that meeting at least one of the above criteria is associated with a more than tenfold increase in the risk of developing breast cancer.

Preventive mastectomy - indications

Preventive mastectomy is a surgical procedure with a risk of he alth complications, just like other operations. Qualification for preventive mastectomy requires individual consideration of indications in each patient. Presence must be taken into accountrisk factors for breast cancer, and the patient's overall he alth and preferences.

In Poland, preventive bilateral mastectomy is reimbursed for patients at the highest risk of developing breast cancer. They include patients with a confirmed BRCA1 or BRCA2 mutation (about 100,000 women in total), as well as patients with a very burdened family history.

Patients who meet the described medical requirements must give their informed consent to the procedure. It is also necessary to have a general he alth condition that allows qualifying for surgery (no contraindications to surgery and anesthesia).

The criteria described above refer to preventive bilateral mastectomy in patients with a very high risk of breast cancer. Many doubts about prophylactic mastectomy concern women who have already been diagnosed with breast cancer.

At diagnosis of cancer, many patients at genetic risk expect prophylactic removal of the other breast. From a medical point of view, such unilateral prophylactic mastectomy is not always justified.

A patient who has contracted breast cancer requires, first of all, a thorough diagnosis, determining the stage of the cancer, and then appropriate treatment. The prognosis then depends primarily on the chance of a full cure of the existing neoplasm. Prophylactic removal of the second breast does not always improve it, but it is always associated with the risk of postoperative complications.

Preventive mastectomy of the second breast can be considered when the prognosis is favorable and there is a chance for the first neoplasm to fully heal (disease detected early, no spread to other organs, good response to treatment). If breast cancer is found in the advanced stage, priority should be given to treating the primary disease. It should also be emphasized that preventive mastectomy of the second breast should only be considered in patients with a confirmed genetic burden (BRCA1 / 2 mutations).

Scientific research has not proven the effectiveness of this procedure in women without genetic risk factors. Patients who have been diagnosed with breast cancer in the past are always under close oncological supervision. Regular examinations are aimed at early detection of possible recurrence or new tumor foci.

Preventive mastectomy - course

Qualification for preventive mastectomy is usually done by oncology clinics. The entire procedure may take up to several months. It is necessary to document the indications for the procedure(e.g. presenting the results of genetic tests confirming the presence of the BRCA1 or BRCA2 mutation). It is also required to have an up-to-date MRI breast examination (maximum 12 months ago).

Then a surgical consultation is carried out, during which the scope of the procedure and possible breast reconstruction are determined. In the absence of significant he alth contraindications, the date of the operation is set. A patient qualified for the procedure must give her informed consent for it to be performed.

The treatment of preventive bilateral mastectomy begins with the administration of anesthetic drugs. The operation is usually performed under general anesthesia. The surgeon then performs the removal of the mammary glands.

During the procedure it is necessary to completely remove all breast tissue. Leaving the breast gland fragments does not fully minimize the risk of cancer development. Contrary to therapeutic mastectomy, where it is sometimes necessary to remove the surrounding tissues (muscles, lymph nodes), preventive mastectomy only requires complete removal of the breast tissue.

Scientific research has considered the effectiveness of preventive mastectomy while saving the outer shell of the breast (the so-called subcutaneous mastectomy). This is a type of mastectomy that is used in some breast cancer surgery centers.

Currently, however, most preventive mastectomies are performed in a traditional way. The technique of the procedure enables better insight into the surgical field and reduces the risk of leaving pieces of the breast after surgery.

Depending on the patient's preferences and the absence of medical contraindications, preventive mastectomy may be combined with simultaneous breast reconstruction. Currently, the reconstruction of the breast glands after prophylactic mastectomy is one of the services reimbursed by the National He alth Fund. Reconstructions are made with the use of special prostheses and meshes, supporting the implants in the right position.

Preventive mastectomy is considered relatively safe, but like any surgery, it carries a certain risk of complications. The most common are pain, bleeding and infection of the surgical wound.

Preventive mastectomy may also worsen the patient's mental state, which is why many women decide to use psychological support after the procedure.

Preventive mastectomy - effectiveness

The effectiveness of preventive mastectomy depends on the indications to be performedthe procedure and the group of patients in whom it was performed. The greatest efficacy has been demonstrated among patients burdened with the BRCA1 / 2 gene mutation, who underwent bilateral prophylactic mastectomy.

The treatment reduces the risk of breast cancer by as much as 90-95%. Preventive mastectomy does not provide a full, 100% guarantee of cancer avoidance. This is mainly due to the technical limitations of the procedure - removal of all visible breast tissue does not exclude the possibility of leaving microscopic remnants of glands, which may become the starting point for the cancer in the future.

Patients who are carriers of the BRCA1 or BRCA2 mutation, in addition to an increased risk of breast cancer, are also at a higher risk of developing ovarian cancer. For this reason, some of them also have prophylactic removal of the ovaries and fallopian tubes.

Interestingly, the effectiveness of such a procedure has also been proven in the prevention of breast cancer. However, this effectiveness is significantly lower compared to preventive mastectomy. Bilateral removal of the appendages (ovaries and fallopian tubes) in BRCA1 or BRCA2 mutation carriers reduces the risk of breast cancer by 50%.

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Category:

Oncology