If you’re facing mastectomy of one of your breasts, what should you decide about the other? Increasingly, women are choosing contralateral prophylactic mastectomy (CPM) of their opposite healthy breast to reduce their future risk of breast cancer. But health experts are concerned that many women who choose CPM don’t really “need” it. CPM is not typically recommended for women of average risk who are diagnosed with early-stage disease because it has not been found to improve survival. National Comprehensive Cancer Network guidelines recommend CPM on a case-by-case basis for women who have a high risk of breast cancer, including those who have a BRCA gene mutation—their risk for contralateral breast cancer is higher than women who do not have an inherited predisposition to the disease (only 5-10 percent of breast cancer diagnoses are caused by a genetic mutation). Counseling regarding CPM may also be advised for women with a strong family history of breast cancer.
If contralateral breast cancer is a low risk for most women, why are so many making the difficult decision to sacrifice their healthy breasts, even when doctors tell them it isn’t really necessary? Here are some reasons for the rising CPM rate:
· Women often overestimate their risk of a new breast cancer. Studies show that women commonly believe their breast cancer risk is far greater than it really is. For most women, the risk of developing breast cancer in the opposite breast is quite low—an estimated 3-9 percent of women who have lumpectomy or unilateral mastectomy develop breast cancer in the opposite breast. So, most women who hear “you have breast cancer” in one breast are not as likely to hear it again regarding their remaining breast. The risk of developing breast cancer in the second breast is greater for women who have tumors in more than one area of the breast, invasive lobular cancer, a BRCA gene mutation or a strong family history of breast cancer.
· Increased use of MRI scans before mastectomy. Use of pre-mastectomy MRI, which sometimes shows early-stage abnormalities in the healthy breast, is more common now than in previous years. Although MRI may produce false positive results, women who have a pre-operative MRI are more likely to request a CPM.
· Fear of going through it all again. Facing mastectomy of one breast, many breast cancer patients decide to remove their opposite breast, even if the risk of breast cancer is remote. They would rather “get it all over now” than face another diagnosis, treatment and potentially another mastectomy in the future.
· Better reconstructive results. For women who want breast reconstruction, many feel their new breasts will be more symmetrical if they are reconstructed at the same time, rather than trying to match a reconstructed breast to a natural breast. After unilateral mastectomy, however, (and in the hands of a skilled plastic surgeon) a recreated breast of natural tissue can closely match the size, position and shape of the opposite healthy breast, which can also be augmented, reduced or lifted for improved contour, size and symmetry.
Should you let what you know in your head (that your risk of a new cancer is quite low) override what you feel in your heart (the need to do anything possible for peace of mind)? Even after knowing that your actual risk of a future breast cancer is lower than your perceived risk, you may decide that you won’t be able to sleep at night waiting for another diagnosis.
Not all decisions are straightforward or easily made. Deciding about CPM is complex, difficult and very personal. Whatever you ultimately decide, first allow yourself time to consult with a genetics expert who can estimate your future risk and discuss how risk management alternatives can reduce that risk. Consider your options, and weigh the pros and cons of each one (making a list helps). If you are concerned with reconstruction, talk to two or three reconstructive surgeons about your potential outcome. Then make the informed decision that is best for you.