Cancer surgeons advise against removal of healthy breast
The new position statement from the American Society of Breast Surgeons comes at a time when more breast cancer patients are asking doctors to remove the unaffected breast—a procedure known as contralateral prophylactic mastectomy.
"Contralateral prophylactic mastectomy is a growing trend that has generated significant discussion among physicians, patients, breast cancer advocates and media," said position statement lead author Dr. Judy Boughey. She is professor of surgery at Mayo Clinic in Rochester, Minn.
However, "it is important for patients to understand it does not improve their cancer outcome and for them to understand the pros, cons and alternatives to [contralateral prophylactic mastectomy]," she said in a society news release.
The surgeons' group believes the procedure should generally be discouraged in average-risk women, whose chances of developing breast cancer in the healthy breast are only 0.1 to 0.6 percent a year.
And research shows that most women with cancer in one breast gain no cancer-prevention benefit from removal of the healthy breast, the society said.
One group at high risk, for whom the surgery might be warranted, includes women with BRCA 1 or BRCA 2 gene mutations. This was the type carried by actress Angelina Jolie, who did not have breast cancer but who underwent prophylactic double mastectomy in 2013 to lessen her chances for the disease.
According to the guidelines, other women who may opt for contralateral prophylactic mastectomy are those with a lifetime breast cancer risk greater than 25 percent who have not had genetic testing, or those who received "mantle" radiation before age 30. The mantle field includes the lymph node areas in the neck, chest, and under the arms.
The surgery may also be appropriate for women with other genetic risks; a strong family history of breast cancer; dense breasts; extreme disease-related anxiety; or concerns about breast reconstruction symmetry.
"Typically, the decision to perform a contralateral procedure is based on a combination of the patient's perceived risk and fear of future breast cancer, anxiety about annual screening and possible additional diagnostic procedures, as well as the uncertainty of physical, emotional and cosmetic surgical outcomes," said statement senior author Dr. Julie Margenthaler. She is a professor in the division of general surgery at Washington University School of Medicine in St. Louis.
Surgeons should make a clear recommendation for or against the surgery from a medical standpoint to each patient, the authors said.
However, patients' values and preferences should also be an important part of a shared decision-making process, according to the statement.
"The society believes that a final treatment plan should be based largely on an analysis of the risks and benefits of contralateral mastectomy, and the patient's perspective on surgery," Margenthaler said.
She added: "Patient education on those risks and benefits, all treatment options and recurrence risks are crucial. A well-planned patient-surgeon discussion to facilitate this is extremely important."
Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City, reviewed the new guidelines. She agreed with the advisory, but said the ultimate decision must always be in the patient's hands.
"If a woman is properly counseled and concludes that she wants to move forward with the surgery, a bilateral mastectomy is still an option," Bernik said.
Sometimes breast aesthetics are part of the decision process, she noted.
"One of the most common reasons for a bilateral mastectomy is for symmetry, and this is still a legitimate reason to go forward with removal of both breasts," Bernik said.
"A few of the other reasons include strong family history, aversion to ongoing testing, and extreme emotional anxiety due to testing," she said.
The statement was published July 28 in the journal Annals of Surgical Oncology.
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