Editor’s note: Cancer Q&A is a monthly column in which health professionals from Baystate Regional Cancer Program, based in Springfield, address issues related to cancer in a question and answer format.
For a woman who is diagnosed with breast cancer, the question about whether or not to remove the other healthy breast, known to physicians as a contralateral (definition: other side) prophylactic mastectomy (CPM), may be at the forefront of her mind.
Requests for double mastectomies have grown dramatically over the past decade, especially since actress Angelina Jolie’s very public decision to have one. However, research has not shown that it is beneficial for most patients to have both breasts removed rather than only the breast with cancer.
The American Society of Breast Surgeons recently released a position statement with recommendations concerning the use of contralateral prophylactic mastectomy to help patients and physicians make informed choices concerning this procedure.
Q. When should a woman consider CPM?
A. If a woman diagnosed with breast cancer has been found to have the BRCA gene mutation, her risk of developing breast cancer again in her lifetime is high enough to warrant consideration of removing the other breast.
There are other gene mutations that have been discovered, but the magnitude of the risk for those patients is less well understood.
There are situations where a woman may have a very strong family history for breast cancer without there being a known BRCA gene mutation. Double mastectomy can be considered in those cases.
Some women may have received chest wall radiation as part of treatment of another cancer, typically Hodgkin’s Lymphoma. If that has happened before the age of 30, a woman’s chance of developing breast cancer is increased sufficiently, and a CPM could be considered.
Q. Why has the American Society of Breast Surgeons come out with these new recommendations?
A. Studies have shown a dramatic increase in the number of double mastectomies occurring over the last 15 years. Unfortunately, we have learned that the likelihood of having complications after surgery — such as infection, bleeding, the need to return for more surgery, loss of the reconstruction, or chronic pain — is doubled when two mastectomies are performed instead of one.
This can hurt a patient’s long-term prognosis if the other treatments that are needed to treat the breast cancer, such as chemotherapy or radiation, are delayed.
In addition, we are gaining a better understanding about the psychological and emotional impact of having the second breast removed, such as decreased self-image or decreased sexuality, without finding an improvement in quality of life.
Up to 20 to 30 percent of patients will report that results of the procedure, whether physical, in terms of appearance, or psychological, are worse than expected.
Q. What, if any, is the survival advantage of having both breasts removed?
A. This is the heart of the matter. Except for patients who have been found to have a gene mutation that predisposes them to develop breast cancer, such as the BRCA mutation, there is no survival benefit to removing the second breast.
Q. Then what are the advantages?
A. When a woman has both breasts removed, there will no longer be a need for screening mammograms.
Having both breasts removed at the same time provides the best chance that the reconstructed breasts will look the same — what is called symmetry.
Many women will consider CPM in order to alleviate anxiety concerning development of cancer in the other breast. Unfortunately, there is no way to know whether or not a woman will develop cancer in that other breast in the future. The reality is that the cancer she has now is what will determine her long-term survival, and the focus needs to be on treating that cancer appropriately.
Q. How can physicians address their patients’ fears of cancer reoccurrence before resorting to such an aggressive treatment?
A. Breast cancer recurrence can emerge within the breast that has cancer now or elsewhere in the body. Removing the second breast does not lower that risk. What helps to reduce the risk is the medicine — chemotherapy, anti-hormone therapy — that will be given.
The key to decision-making concerning removal of the other breast is a thoughtful discussion between a physician and the patient about the risks and benefits of CPM. The timing of CPM — whether now or at a later time — should be flexible to allow for treatment of the cancer without delay. Removing the other breast should not be given the same sense of urgency as surgery for the breast with cancer.
Ultimately, the physician’s role is to provide a woman with the information that will allow her to make a decision that is right for her.
Dr. Holly Mason is section chief, breast surgery, Division of Surgical Oncology at Baystate Regional Medical Center in Springfield.