A mastectomy is usually thought of as a treatment for breast cancer. But in some women, surgery may be considered even when cancer has not been diagnosed. This is known as a risk reducing mastectomy, also called a prophylactic mastectomy.
The decision to have this surgery is deeply personal. It is not the right choice for everyone at high risk of breast cancer. Understanding your actual risk, the available alternatives and what surgery involves can help you make a decision that feels right for you.
Who may consider a risk reducing mastectomy?
Risk reducing mastectomy is generally considered when a woman has a significantly higher than average risk of developing breast cancer.
This may include women who carry certain inherited genetic mutations, such as BRCA1 or BRCA2. Other inherited gene changes can also increase breast cancer risk. A strong family history of breast or ovarian cancer may be another reason to discuss genetic counselling and risk assessment.
Women who have already had cancer in one breast may also discuss surgery on the other breast, called a contralateral risk reducing mastectomy. However, having cancer in one breast does not automatically mean that the other breast needs to be removed.
The important point is that being at high risk does not automatically mean you need surgery. Your individual risk needs to be assessed before making such a decision.
How much can surgery reduce the risk?
Risk reducing mastectomy can substantially lower the chance of developing breast cancer because most breast tissue is removed. However, it does not reduce the risk to zero. A small amount of breast tissue may remain after surgery, and breast cancer can rarely develop in this residual tissue.
For some women with a very high inherited risk, the reduction in risk can be an important reason to consider surgery. For others, regular screening and preventive medicines may provide an acceptable alternative.
This is why the decision should be based on your individual risk rather than fear alone.
What are the alternatives?
Before choosing surgery, it is worth discussing all available options with your breast specialist.
Depending on your age, family history, genetic results and other factors, you may be offered closer breast surveillance with tests such as mammography and breast MRI. Some women may also be candidates for medicines that can reduce the risk of developing hormone sensitive breast cancer.
Genetic counselling can be particularly helpful if you have not already undergone genetic testing. Understanding whether you carry a particular inherited mutation can provide important information about your breast and ovarian cancer risks and may influence decisions about screening and preventive surgery.
What does the surgery involve?
A risk reducing mastectomy removes most breast tissue while preserving as much healthy skin as appropriate. In some cases, the nipple and areola can also be preserved.
Breast reconstruction may be performed during the same operation or at a later stage. Reconstruction can use implants or your own tissue, depending on your body, preferences and medical circumstances.
It is important to understand that reconstruction is not simply a cosmetic procedure. It is part of the overall surgical journey and may involve more than one procedure.
Your surgeon should explain the expected appearance, recovery time, possible complications and limitations before you make your decision.
What are the possible risks?
Like any major operation, prophylactic mastectomy has risks. These can include infection, bleeding, wound healing problems, changes in sensation and complications related to reconstruction.
Some women experience numbness or altered sensation in the breast or chest area after surgery. There can also be emotional effects. Even when surgery was chosen to prevent cancer, losing one or both breasts can bring feelings of grief, anxiety or uncertainty.
It can be helpful to speak with a breast reconstruction specialist, genetic counsellor or psychologist before surgery if you feel you need additional support.
Take time before making the decision
There is no need to rush into a risk reducing mastectomy simply because you have been told that your breast cancer risk is high.
Ask your doctor:
1. What is my estimated lifetime risk of breast cancer?
2. Do I need genetic testing or counselling?
3. How much would surgery reduce my risk?
4. What screening options are available if I do not have surgery?
5. What type of mastectomy would be suitable for me?
6. Would reconstruction be possible?
7. What complications and long term changes should I expect?
A second opinion can also be valuable, particularly when the decision is difficult.
Dr. Pragati Singhal
