Reduced Anxiety after Prophylactic Mastectomy
A study just published in the British Medical Journal found that women at high risk for breast cancer who opted for prophylactic mastectomy significantly reduced their anxiety levels about getting the disease. Furthermore, they suffered no detrimental impact on their body image or their sexual activity.
Prophylactic mastectomy involves the removal of one or both (bilateral) breasts when there is no clinical sign of cancer. It is a drastic preventive measure undertaken by women who consider themselves to be at extremely high risk for the disease.
Dr. Lesley Fallowfield of the Royal Free and University College Medical School in London and colleagues surveyed 79 high-risk women who underwent prophylactic mastectomy and 64 similarly at-risk women who declined to have the operation. They found that the women who opted for the surgery had much lower anxiety levels about their breast cancer risk at 6 and 18 months after the procedure.
Furthermore, the researchers noted that women who had the surgery (most of whom had immediate reconstruction) maintained a positive body image and reported few or no changes in sexual activity during the follow-up period.
Fallowfield's team cautioned that some women making this major treatment decision may have an inaccurate perception of their risk of developing breast cancer, prompting them to consider prophylactic mastectomy when it may not have been necessary.
Significantly more "acceptors" of the prophylactic mastectomy option believed that their development of breast cancer was inevitable, they wrote, compared to the majority of "decliners" who believed that heightened screening was an adequate alternative.
An earlier report published in the Journal of the American Medical Association similarly found that a majority of women are satisfied with their decision to have undergone bilateral prophylactic mastectomy due to their high risk for breast cancer.
Dr. Marlene Frost and colleagues from the Mayo Foundation and Clinic in Rochester, Minnesota, interviewed 572 women with a family history of breast cancer who had a bilateral prophylactic mastectomy between 1960 and 1993. They found that 70 percent of the women were satisfied with their decision and two-thirds of them would "definitely" or "probably" choose to have the procedure again. Furthermore, 74 percent of the women said they are now less concerned about developing breast cancer.
Last year Mayo Clinic researchers reported that prophylactic bilateral mastectomy reduces the risk of breast cancer by about 90 percent in women at high risk due to a family history of breast cancer. And at the recent annual meeting of the American Association for Cancer Research, Mayo's Dr. Lynn Hartmann further reported that women at genetic risk who carry the BRCA1 and BRCA2 gene mutations also have a 90 percent risk reduction after this procedure.
"Prophylactic mastectomy appears to reduce the risk of breast cancer in mutation carriers to the same degree that it does in women who are considered high risk on the basis of family history alone," Hartmann said.
While prophylactic bilateral mastectomy appears to be effective, it remains extremely controversial. The procedure involves major surgery and is usually followed by breast reconstruction. Women who are high risk and are considering the procedure are usually given at least two other options: very careful monitoring (which most women choose), and chemoprevention with tamoxifen.
Another study, led by Dr. Timothy Rebbeck of the University of Pennsylvania, found that women with BRCA1 gene mutations can cut their risk of developing breast cancer by as much as 72 percent by undergoing bilateral prophylactic oophorectomy, which involves the surgical removal of the ovaries.
Writing in the Journal of the National Cancer Institute, Rebbeck cautioned that the potential benefits of the oophorectomy procedure must be weighed against the "primary negative side effect of the surgery-the induction of premature menopause-which increases a woman's risk of osteoporosis and heart disease." An accompanying editorial by Dr. Kathy Helzlsouer of the Johns Hopkins School of Public Health noted that women in their study who subsequently used hormone replacement therapy were able to counteract these risks while still obtaining some of the benefits that ovary removal had for breast cancer prevention. Women with BRCA1/2 mutations consider oophorectomy because of their increased risk of ovarian cancer.
Prophylactic mastectomy is not a guarantee against cancer, because 100 percent of the breast tissue cannot be removed. Some women have developed breast cancer after the surgery. And even among women at high risk for the disease, it remains a controversial option because of the significant physical and emotional impact of the surgery.
Nonetheless, for women who consider breast cancer to be a life-threatening risk-because of a strong family history, genetic markers or other factors-it may be an option worth serious consideration.
SOURCES:
British Medical Journal, January 13, 2001; 322: 76-79
Journal of the American Medical Association, July 19, 2000; 284: 319-324
The Mayo Clinic (www.mayo.edu)
Abstracts from the Society of Human Genetics conference, October 22, 1999
Abstracts from the annual meeting of the American Association of Cancer Research, April 4, 2000
Journal of the National Cancer Institute, Sept. 1, 1999; 1442-1443, 1475-1479
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