Only
certain women with cancer in one breast should have their healthy breast
removed in an attempt to prevent cancer, a leading group of breast surgeons
maintains.
The new
position statement from the American Society of Breast Surgeons comes at a time
when more breast cancer patients are asking doctors to remove the unaffected
breast—a procedure known as contralateral prophylactic mastectomy.
"Contralateral
prophylactic mastectomy is a growing trend that has generated significant
discussion among physicians, patients, breast cancer advocates and media,"
said position statement lead author Dr. Judy Boughey. She is professor of
surgery at Mayo Clinic in Rochester, Minn.
However,
"it is important for patients to understand it does not improve their
cancer outcome and for them to understand the pros, cons and alternatives to
[contralateral prophylactic mastectomy]," she said in a society news
release.
The
surgeons' group believes the procedure should generally be discouraged in
average-risk women, whose chances of developing breast cancer in the healthy
breast are only 0.1 to 0.6 percent a year.
And
research shows that most women with cancer in one breast gain no
cancer-prevention benefit from removal of the healthy breast, the society said.
One group
at high risk, for whom the surgery might be warranted, includes women with BRCA
1 or BRCA 2 gene mutations. This was the type carried by actress Angelina
Jolie, who did not have breast cancer but who underwent prophylactic double
mastectomy in 2013 to lessen her chances for the disease.
According
to the guidelines, other women who may opt for contralateral prophylactic
mastectomy are those with a lifetime breast cancer risk greater than 25 percent
who have not had genetic testing, or those who received "mantle"
radiation before age 30. The mantle field includes the lymph node areas in the
neck, chest, and under the arms.
The
surgery may also be appropriate for women with other genetic risks; a strong
family history of breast cancer; dense breasts; extreme disease-related
anxiety; or concerns about breast reconstruction symmetry.
"Typically,
the decision to perform a contralateral procedure is based on a combination of
the patient's perceived risk and fear of future breast cancer, anxiety about
annual screening and possible additional diagnostic procedures, as well as the
uncertainty of physical, emotional and cosmetic surgical outcomes," said
statement senior author Dr. Julie Margenthaler. She is a professor in the
division of general surgery at Washington University School of Medicine in St.
Louis.
Surgeons
should make a clear recommendation for or against the surgery from a medical
standpoint to each patient, the authors said.
However,
patients' values and preferences should also be an important part of a shared
decision-making process, according to the statement.
"The
society believes that a final treatment plan should be based largely on an
analysis of the risks and benefits of contralateral mastectomy, and the
patient's perspective on surgery," Margenthaler said.
She
added: "Patient education on those risks and benefits, all treatment
options and recurrence risks are crucial. A well-planned patient-surgeon
discussion to facilitate this is extremely important."
Dr.
Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York
City, reviewed the new guidelines. She agreed with the advisory, but said the
ultimate decision must always be in the patient's hands.
"If
a woman is properly counseled and concludes that she wants to move forward with
the surgery, a bilateral mastectomy is still an option," Bernik said.
Sometimes
breast aesthetics are part of the decision process, she noted.
"One
of the most common reasons for a bilateral mastectomy is for symmetry, and this
is still a legitimate reason to go forward with removal of both breasts,"
Bernik said.
"A
few of the other reasons include strong family history, aversion to ongoing
testing, and extreme emotional anxiety due to testing," she said.
The
statement was published July 28 in the journal Annals of Surgical Oncology.
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