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Bilateral Mastectomy for Breast Cancer

By Richard C. Frank, MD

When a famous person is affected by illness, especially one as serious as cancer, they may publicly share their experiences and when they do, the world takes note. When First Lady Betty Ford went public with the her battle with breast cancer that included a mastectomy (removal of the whole breast) in the 1970s, the “C word” came out of the closet, igniting a revolution in patient advocacy. Mrs. Ford’s courage led to women taking charge and demanding less disfiguring surgery, breast preservation when possible and attention to their physical and emotional needs.

Many years of research and the brave participation of thousands of women in clinical trials proved that for local control of cancer in the breast, the less-invasive “lumpectomy” (removal of only the cancerous tumor) followed by radiation to the breast was equal in efficacy to mastectomy. This changed the approach to breast cancer for millions of women and has allowed the vast majority to preserve their breasts despite a cancer diagnosis.

Recently, however, the pendulum has begun to swing back and an increasing number of women are choosing to undergo mastectomy or even bilateral mastectomy (removal of both breasts), for a variety of reasons. Two women in the public eye,  actress Christina Applegate and E! News host Giuliana Rancic have publicly discussed their decision to undergo bilateral mastectomy. Their reasons differed and will be discussed below.

For women who have an inherited predisposition to breast cancer, removing both breasts can reduce the risk of developing breast cancer by over 90%. An inherited predisposition is indicated by a strong family history of breast cancer. Many (but not all) such women will be found to have an abnormality or mutation in the breast and ovarian cancer susceptibility genes BRCA1 and BRCA2. This was the case for Ms. Applegate. Her decision to remove both breasts was purely preventative; she did not have breast cancer.

For women diagnosed with breast cancer, the cancer will be one of two types: noninvasive or invasive. A non-invasive cancer (also called DCIS, which stands for ductal carcinoma in-situ) means that when the pathologist analyzes the specimen, the cancer is well-contained and does not penetrate the tissue barriers around it.  Such a cancer does not have the ability to spread (metastasize) to other parts of the body, so it is curable by treatment of the breast with lumpectomy and radiation or mastectomy. Regardless of which procedure is chosen, however, the hormone therapy tamoxifen is often recommended in order to prevent a recurrence of breast cancer. If both breasts are removed, then there would be no need for tamoxifen or radiation. Some women who choose mastectomy for the affected breast are also choosing to undergo a prophylactic mastectomy in the unaffected breast. One of the main reasons given is that they will “never have to do this again.”

Although I do not know the details of Ms. Rancic’s cancer, from her interview it would seem that she had non-invasive cancer in both breasts and that a bilateral mastectomy would relieve her of the need for any further therapy. It would also provide psychological relief by eliminating the need to undergo regular breast cancer screenings with mammograms, ultrasounds, or MRIs.

On the other hand, when the pathologist deems that a cancer is “invasive,” this means that it has the potential to spread to other parts of the body. Regardless of which treatment is chosen for the breast (lumpectomy plus radiation or mastectomy), hormone therapy, and/or chemotherapy may be indicated to lower the risk of metastasis  as well as the chances of a new cancer developing in the unaffected breast.

As discussed for noninvasive breast cancer, some women with invasive breast cancer choose to have a bilateral mastectomy. This will not affect the risk of metastasis from the original cancer or change the recommendation for hormonal therapy or chemotherapy. It will, however, greatly reduce the chances of developing a new breast cancer and eliminate the need for ongoing breast cancer screenings.

The bilateral mastectomy is not without its negative consequences, which must be considered. Reconstructive surgery can cause discomfort and involve many months of treatment. Some women may experience an altered body image and effects on sexuality. There are many other considerations, some of which are mentioned in the above links.

Because of space limitations and the complexity and sensitivity of this topic, I cannot fully do it justice. Nothing can replace speaking with your physicians about the risks and benefits of procedures such as the bilateral mastectomy.

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