As I was persuing the New York Times March 9th, I came across an article discussing an increasing trend towards women with breast cancer wanting to remove their other healthy breast (prophylactic mastectomy). As a breast surgeon it is not only important to give women with breast cancer all of their surgical options, but to understand the emotional and psychological aspects of their decision making process. While it is true that removing a healthy breast in a woman diagnosed with breast cancer does not impact overall survival, there are many other issues at play that can be addressed by prophyalctic surgery.
First and foremost, women with larger breast cancers (> 4cm), numerous small breast cancers in more than one location in one breast, or even women with DCIS (stage 0 breast cancer) that encompasses a majority of the breast have mastectomy (removal of the breast) as their only surgical option for treating their breast cancer. Many of the women who have had unilateral mastectomy with implant reconstruction or reconstruction with their own tissue find that they do not look symmteric and/or have difficulty buying clothing/bras that fit properly after surgery. This can be very frustrating and extremely anxiety provoking. Many of these women have stated that if they knew prior to their surgery what they know now, they would have opted to remove the other breast for symmetry.
Second, there are women with small breast cancers amenable to breast conserving surgery and radiation as well as women who have had unilateral mastetcomies who are paralyzed with fear at the thought of continued monitoring with imaging, exams and the potential for multiple biopsies dwon the road. When I say paralyzed with fear-I mean must take medication to even perform their activities of daily living. These women are always waiting for the other shoe to drop and frankly, that is no way to live when there are other options available. I think it requires in depth conversations with the breast surgeon, the patient and perhaps even a psychologist or psychiatrist with a special focus on the issues women with breast cancer face prior to proceeding with bilateral mastectomies in this group of patients.
Third, some women flat out do not want radiation-period, end of story. In those situations where radiation would be necessary, the only other surgical option is mastectomy and again we re-visit the issues of symmetry and quality of life.
It is vitally important that women facing mastectomy know all the potential risks associated with the mastectomies and reconstruction: 1. Loss of sensation over the skin flaps, 2. Infection with implants, 3.Scar tissue formation and deformation of the implant, 4. Rupture of the implant, 5. Loss of a tissue flap (ieTRAM) and again you must stress the fact that having a prophyalctic mastectomy makes no difference in terms survival as compared to the less invasive operation of lumpectomy with radiation. If you have this conversation with your patients and you are sure they 100% understand all of what you are telling them and they still provide a compelling argument for why they want to remove their healthy breast-then I think, as a surgeon, you have to be willing to listen! At Montclair Breast Center, our patients play an active role in the decision making process for their treatment course.
One last note, our plastic surgery colleagues techniques have advance so rapidly that the cosemtic results after mastectomies for breast cancer look and feel very close to natural. They do amazing work!
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