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Bilateral Mastectomy to Prevent Breast Cancer? A Very Difficult Decision

One out of nine American women will likely face one of the most terrifying killers of our time, breast cancer. Traditionally, preventive measures have ranged from self-exams and breast imaging to chemoprevention (hormonal therapy and tamoxifen). But a new study, published in Thursday's New England Journal of Medicine, that was conducted at the Rotterdam Family Cancer Clinic in the Netherlands, has found that a radical surgical procedure substantially reduces the incidence of breast cancer in high-risk patients. The procedure, a prophylactic bilateral mastectomy, removes the breasts when there is no cancer present. It's a drastic preemptive strike against the disease for women considered to be "high risk."

Each year more than 180,000 new cases of breast cancer are diagnosed in the US, and over 40,000 women die of the disease each year. Women who carry one of the so-called breast cancer genes--BRCA1 or BRCA2--have a 55 to 85% chance of getting breast cancer and a 15 to 65% risk of ovarian cancer.

The Early Show talks with Dr. Michael Osborne, chief of breast service at New York Hospital-Cornell Medical Center, will tell us more about this drastic procedure and the study's implications.

Can you explain to me what this procedure is?

A bilateral prophylactic mastectomy is when the surgeon removes all of the breast tissue and leaves little or no breast tissue behind in an attempt to prevent the disease of breast cancer from occurring. We remove the glandular tissue under the skin but conserve the skin and then work with a plastic reconstructive surgeon to replace that breast tissue with either a saline (salt water) implant or the patient's own tissue from their lower abdominal area.

Is it possible to remove all the breast tissue?

No, it's not possible technically to remove every last trace of breast tissue because the tissue is not all in the breast. There are very small amounts in the surrounding area. Women should be aware that residual breast tissue leaves an undefined but small risk of developing breast cancer even after a BPM--a bilateral prophylactic mastectomy. But the remaining tissue doesn't usually present a practical problem.

When did you first start performing this procedure?

I've been performing these procedures for the last 20 years. In earlier days it was based just on a family history of breast cancers or other risk factors, such as noncancerous tissue changes seen after a breast biopsy. More recently we have been basing it on a better-defined risk--if they are a carrier of a particular gene abnormality that puts them at risk.

How do you evaluate who is a good candidate for this procedure? What are you looking for?

For those who are interested in having a prophylactic mastectomy, we are looking for individuals in good health who have a long life expectancy and who have a very high risk.

The key risk factors for breast cancer would e a family history associated with an inherited gene that carries a mutation that leaves the patient with a very high risk. Another key risk factor is changes in breast tissue after a biopsy. These changes in tissue are not malignant but they are changes that indicate that breast cancer is more likely to occur in the future. For those that have both the gene and the tissue changes it is likely that their risk is extremely high.

Two groups of women should consider this procedure: One group consists of those who have had breast cancer in one breast and elect to have the other breast removed. This is called a contralateral prophylactic mastectomy. The other group is those women who we know are at high risk--women with a strong family history of breast cancer. Especially families in which women younger than 40 or multiple family members have breast cancer. And, those who've had genetic testing and carry BRCA1 or BRCA2, the so-called breast cancer genes. Studies have predicted that wmen with these genes have an 85% chance of developing breast cancer over their lifetime. Also, Another group is women who become incapacitated by the fear of developing breast cancer.

This is an extraordinarily radical procedure. Iis this the procedure that you think women should consider?

I believe that no woman should be told that she should have a prophylactic mastectomy. I think her physician needs talk to her about the risk and evaluate those risks each year and project what the risk will be over her lifetime. The physician also needs to be sure to tell her that prophylactic mastectomy is not the only option.

What are some of the other options?

Other options include close surveillance. Advances are being made in that area for very early detection. There are also preventive drugs like the anti-estrogen tamoxifen, which can reduce the risk by about 50%.

How does the patient decide which course is best for her?

If a woman is looking not to reduce the risk but just to have early detection then surveillance is a good option. If she is looking to reduce the risk but doesn't want to go through such a radical procedure then an anti-estrogen such as tamoxifen may be right. If she wants to minimize the risk down to the lowest level possible, which looks to be 99% or better, then a prophylactic mastectomy is the only option available to get to that level of risk reduction.

Aren't the methods of early detection getting so sophisticated that this procedure may not be necessary or worthwhile?

We are not at the point where we can say that surveillance is so sophisticated--although things are moving in that direction--that we can't say that this surgery is the safest option. Recent studies show that prophylactic mastectomy offers a woman the greatest risk reduction, giving her the lowest risk of developing breast cancer in the future.

How effective is this procedure in prevening breast cancer?

The one thing that recent studies--there have been two of them--have shown, although they are early studies, is that prophylactic mastectomy is highly effective in preventing breast cancer. We can never say to a patient that it is 100% guaranteed that they will never get breast cancer because there is some breast tissue that is outside the anatomical area of the breast. But in reality, in the practical sense, that is a minuscule risk. The risk reduction is very high, in the 98 to 99% area, and that is as good as it gets currently.

What is the emotional impact of making this decision, or having this surgery?

Deciding to have this surgery is very complicated. It is impacted by many factors. For instance, if a woman has a very strong family history of breast cancer and has multiple relatives with breast cancer--a mother, sisters, grandmother, aunts--and particularly if the outcome of the breast cancer in those relatives has been bad, then she may be very motivated to avoid breast cancer at all costs. A woman's social situation can be an important factor in the decision making--if they are married or single or have young children and don't want to run the risk of getting sick.

If there is a woman out there who knows that she has a family history of breast cancer what is the one question that she should be asking her doctor?

Any woman with a strong family history of breast cancer should be asking her doctor to refer her to a genetic counselor. Genetic counselors are experienced and trained to evaluate risk. Genetic testing for breast cancer is very complicated and very expensive. There are many issues around the testing: Is the test accurate? If I test negative for the gene does that mean that I will never get breast cancer? If I test positive does that mean that I will definitely get breast cancer? There are other genes out there that we still don't know about. There are other implications as well. Will geting this test lead to future discrimination in insurance or employment? The first step is sitting down with a counselor and deciding whether to get this test or not.

Should everybody with this "high risk" get genetically tested?

Nobody should get tested unless they have already figured out what they are going to do with the results. Don't get tested unless you have a plan. What action will you take if you test positive? That is why you need to discuss this with a counselor.

How certain can you be of a woman's risk of getting breast cancer if they are high risk?

The gene for developing breast cancer was discovered in 1995-96 so we've had a few years to study this. A woman with the BRCA1 or 2 gene has an approximately 85% risk of getting breast cancer assuming she lives into her mid-80s. And we know that half of those cases will occur before the age of 55. But the risk varies from patient to patient. We can never tell an individual for certain whether hey will be in that 85% or not.

The risk-to-benefit ratio is part science and part psychological: In a way you're betting on getting cancer. Yes, the potential benefits depend on the risk of getting breast cancer. Women have to weigh the surgical procedure and its complications, discomfort, psychological issues, and self-image and sexual issues against the benefits of risk reduction. Many high-risk women simply choose to rely on self-examination and early detection. This study should give women additional information they need to make such a difficult decision.

Many of the women who participated in the study were young women in their 20s and 30s. Did they all have reconstructive surgeries?

Yes, most did. In 74 of the 76 women who had a BPM in the study, the breasts were reconstructed with silicone prosthetics by a plastic surgeon in the same session, followed later by nipple reconstruction.

What do you tell women who are concerned that this is a disfiguring procedure?

During the breast-tissue removal process, very small incisions are made and very little skin is removed. And we usually undertake immediate reconstruction at the time of the mastectomy. The reconstruction can involve a saline implant (which is very safe) or the patients' own fat and muscle tissue, which we take from the lower part of the abdomen.

From a cosmetic standpoint is there a dramatic visible difference between the old breasts and the reconstructed ones?

You've asked a very difficult question. Each method has different advantages and disadvantages. Saline implants are quick and easy to do. There is good symmetry obtained and the recovery time is short. They are the simplest option but they don't replicate the look of real breasts over time, and they remain higher. Using the patient's own lower abdominal tissue is a bigger operation because now surgery is going to be done at another site. It is a lot longer procedure but the outcome has the a more natural look and feel. The symmetry and appearance are more natural looking. But both are good procedures.
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