Some women at high risk for breast cancer because of an inherited gene mutation, including actress Angelina Jolie, are choosing to have preventive double mastectomies. Other women who have cancer in one breast are asking their doctors to remove the other breast removed out of caution. Whatever the reason, more women are having both breasts removed in response to cancer or a cancer threat. Dr. David Euhus, chief of breast surgery in the division of surgical oncology at Johns Hopkins Hospital, explains the trend and what happens after.
What is a bilateral mastectomy, who is it recommended for?
Bilateral mastectomy is the removal of both breasts. Sometimes a breast has to be removed to treat a cancer, but more and more women are just asking to have both breasts removed. Sometimes both breasts are removed to reduce the risk of ever getting cancer. This is generally reserved for women that are at very high risk for breast cancer because they carry a mutation in a breast cancer predisposition gene like BRCA1, BRCA2, PALB2, or any of the dozen other genes now linked to breast cancer.
Does this surgery lower the risk of breast cancer recurring or improve survival rates?
We used to always say with confidence that whether you treat your breast cancer with lumpectomy or mastectomy, the survival will be the same. There is some evidence now that double mastectomy may be associated with better survival, but this benefit is not apparent until after more than 10 years. This is currently an area of controversy and discussion. For a woman at high risk for breast cancer, a double mastectomy will reduce her risk by more than 90 percent, but so far there is not data to show she will live longer than women who chose not to have a mastectomy.
If doctors don't routinely recommend it, why are rates on the rise?
Patients are driving the sharp increase in the double mastectomy rates. For the last 25 years, we have been encouraging women diagnosed with breast cancer to keep their breasts and just treat the cancer. Over the last 10 years or so, we are seeing more and more women say, "Thank you, no. I want them both removed." There are many reasons for this. One reason is that with new techniques, like the nipple-sparing technique, mastectomies are not nearly as disfiguring as they used to be. The information age is probably driving this a bit as well. There is a lot of attention focused on breast cancer, and nearly everyone knows someone who had to deal with it. Many women already have it in their mind that "If I get it I'm just going to have them both removed."
How is monitoring done after a diseased breast is removed?
We know that it is impossible to get all of the breast tissue because some of it goes right up to the skin. But all mastectomies are not equal. Some surgeons leave a lot of tissue under the skin and others almost none. The recommended follow-up after a mastectomy is to have a doctor examine the area once or twice a year. Mammograms and MRIs are not recommended for most women who have had a mastectomy, but annual imaging might be done if there is still a lot of breast tissue under the skin.