Prophylactic mastectomy – Breast reconstruction
In recent years, the technique of prophylactic mastectomy has become popular in the treatment of breast cancer. In general terms, it is a procedure aimed at removing “healthy” breast tissue in patients with a genetic risk of developing a malignant breast tumor (family history, BRCA1+, BRCA2+ genes, premalignant lesions, etc.).
INDICATIONS FOR PROPHYLACTIC MASTECTOMY
1. One or more first-degree relatives (mother, daughter, sister) with a history of breast cancer during premenopause.
2. Two or more first-degree relatives with a history of postmenopausal breast cancer.
3. History of macrocystic disease, with aspiration of 5 or more cysts that have required aspiration.
4. History of lobular carcinoma in situ.
5. Atypical ductal hyperplasia.
6. Atypical lobular hyperplasia.
7. BRCA 1 or BRCA2 gene mutation.
In the last twenty years this procedure has been fully implemented within breast cancer treatment units. However, in its beginnings it was a technique looked upon with suspicion, since it was a very aggressive technique and its true effectiveness and validity in preventing breast cancer was not known, hence the controversy.
Today, it is estimated that the rate of breast cancer risk reduction after prophylactic mastectomy ranges from 89.5- 98.9%.
Given the aggressiveness of this radical procedure, its performance must be fully justified, since it is not free of complications; therefore, it is necessary to analyze in each case the benefit-risk ratio before establishing the surgical indication.
The increase in the incidence of breast cancer (which is partly due to the increase in life expectancy, and also to the improvement of diagnostic methods that allow us to diagnose it in early stages), as well as the marked “cancerophobia” that many patients exhibit, sometimes leads to the over-indiagnosis of this type of surgery, exposing the patient to unnecessary risks.
An event that contributed to the popularization of this procedure among the general population was that the famous actress Angelina Jolie underwent this intervention in 2013, due to her family risk of suffering from this type of cancer. Since then, many patients ask about this procedure, and would be willing to undergo it even if they are not indicated or suitable candidates, and regardless of the possible complications.
Possible Complications of Prophylactic Mastectomy
Even in the best hands this procedure is not without complications. In a published article[1] in August 2016 in the specialized publication “Plastic And Reconstructive Surgery”, shows the results and complications of a series of 160 patients who underwent the procedure of areola and nipple sparing mastectomy and immediate reconstruction with prosthesis, in the Department of Plastic Surgery at NYU Langone Hospital in New York (USA). The rate of major complications was considerable, with 8.1% skin flap necrosis, 5.6% reconstruction failure, 4.4% areola necrosis, 4.4% prosthesis explant, and 2.5% cellulitis requiring intravenous antibiotherapy. The total rate of major complications is 25%, not counting minor complications, which account for a similar percentage.
For this reason, patients who will benefit from this aggressive surgery must be carefully selected, trying to minimize the risk of complications. And it is precisely one of the keys of this surgery is to achieve a reduction of the risk of breast cancer, while ensuring adequate viability of the remaining breast tissue … sometimes we see that extremely aggressive surgeries are performed that will be the origin of postoperative complications, or that contraindicate or prevent the immediate reconstruction of the breast.
Conservation of the nipple-areola complex
Today it is accepted that in the performance of prophylactic subcutaneous mastectomies it is possible to preserve the nipple-areola complex with guarantees, maintaining oncologic safety. In cases with a good prognosis, if we compare prophylactic mastectomies with and without conservation of the areola and nipple complex, the recurrence rate is similar, practically nonexistent. This is why the current trend is to keep the nipple-areola complex, since its preservation provides a better aesthetic result, and provides psychological benefits and in terms of preservation of the patient’s own image and sexuality, as shown by the questionnaires to assess the quality of life index (Breast-Q).
However, it is necessary to evaluate the characteristics of each patient, and their individualized risk parameters, and a multidisciplinary team specialized in the subject (normally the Breast Pathology Unit Committees) must participate in making the final decision.
[1] “Breast in a Day”: Examining Single-Stage Immediate, Permanent Implant Reconstruction in Nipple-Sparing Mastectomy. Choi M, Frey JD, Alperovich M, Levine JP, Karp NS. Plast Reconstr Surg. 2016 Aug;138(2):184e-91e. doi: 10.1097/PRS.0000000000002333.