Bilateral Mastectomies: a patient�s personal decision

Last week the Seattle Times reported that women diagnosed with early stage breast cancer in one breast are choosing to have bilateral mastectomies to reduce their chances of getting cancer again, but recent research shows that that there is no survival benefit, even in younger women. Researchers at Stanford and the Cancer Prevention Institute of California evaluated the outcomes of over 190,000 women from the California Cancer registry who were diagnosed with breast cancer in one breast between 1998 and 2011. The rate of bilateral mastectomies rose from 2% to 12.3% over the study period, yet there was no survival benefit to bilateral mastectomies versus lumpectomy and radiation.

To those of us who work in the field, this data comes as no surprise; the trend of bilateral mastectomies is a known phenomenon. More than 10 years ago, I remember the chatter among surgeons at national meetings asking if others noticed that more and more, younger women were coming in asking for bilateral mastectomies. Back in 2007, Dr. Todd Tuttle authored a study in the Journal of Clinical Oncology that found that the rate of contralateral prophylactic mastectomy was on the rise, from just under 2% in 1998 to 5% in 2003. This week’s study only validates that this upward trend shows no sign of leveling off.

Why do patients choose bilateral mastectomies?

Many women overestimate the risk of a contralateral cancer. The risk of experiencing a new cancer in the other breast is less than 1% per year for the general population of breast cancer patients. This is a far different risk from women who carry the BRCA 1 and 2 mutations (such as Angelina Jolie) whose risk of breast cancer in both breasts is much higher (60-80%) and therefore bilateral mastectomies are indicated for risk reduction.  We certainly advise genetic counseling and testing to determine a woman’s true level of risk. Many patients comment that they “never want to think about cancer again,” but the highest risk to a woman is not from a new breast cancer in her opposite breast, but the potential distant spread of the cancer she already has. Bilateral mastectomies will not change these odds.

The other reason I hear from my patients is that they want to have “matching” reconstructed breasts, but often don’t realize that symmetry is not a guarantee and that the reconstruction process typically take 6-12 months. Even with skin and nipple preservation, the woman experiences significant loss of sensation over her chest wall.  The most common reason is that my patients never want to have another mammogram or breast MRI ever again. They never want to another biopsy again or experience the anxiety that surrounds imaging. For some women there is a true “burden” to surveillance. But again, I still tell them “I cannot remove and see every breast cell present. I can dramatically reduce your risk, but never to zero.”

So I will continue to inform my patients of the limitations of what surgery can do, doing my best to tell them that having both breasts removed won’t make them live longer or get them out of chemo. I will hand out my articles about the real and perceived risk of a contralateral cancer and the challenges of reconstruction and provide support at this very difficult time. I will ask them to read, to wait, to think carefully before asking for a procedure I can’t reverse and then let them decide. Preventative surgery ultimately remains a personal decision made by each individual patient.