PREVENTION

High Risk Women

A woman is considered High Risk if her lifetime risk of developing breast cancer is greater than 20 percent (1 in 5) (see Risk Assessment).

Risk Reduction Strategies

A. Close Observation

Patients undergo mammogram and breast MRI once a year and breast examination in the office twice a year. In my practice, these patients are enrolled in a special High Risk Clinic where we keep track of them, send appointment reminders, etc. The concept is that if a woman were to develop breast cancer it would be detected early and treatment would likely be effective.

B. Chemoprevention

In this approach, patients take an oral medication such as Tamoxifen or Raloxifene, which interferes with cancer development. The pill doesn’t have to be taken forever. It is taken once a day for 5 years and it reduces the breast cancer risk by 50%. This risk reduction continues over one’s entire lifetime, even though the medication is only taken for 5 years.

If a patient is considering Option B, a Medical Oncologist with a special interest in cancer prevention is consulted. The Medical Oncologist counsels each patient about the risks and benefits of chemoprevention and screens patients for contraindications to the medication. Patients are monitored closely, every 3 months at first, for drug-related problems.

In addition, patients receiving chemoprevention are observed closely in the High Risk Clinic. They receive a breast exam every six months and a mammogram and breast MRI every 12 months as described above.

C. Prophylactic Mastectomy With or Without Reconstruction

Bilateral total mastectomy reduces the risk of breast cancer by 98-99% (you can’t guarantee anything 100%). Put another way, the risk of breast cancer is reduced from 20% (high risk women) to 80% (BRCA mutation carriers) down to 1%.

When the BRCA genes were described in the 1990s and women began to undergo prophylactic (preventative) mastectomies, the entire breast, including all of the skin and the nipple-areolar complex were removed (see Total Mastectomy). Now surgeons remove the breast tissue inside the skin but leave the skin and nipple-areolar complex (see Skin and Nipple Sparing Mastectomy). Reconstruction is almost always done immediately with either implants or the patient’s own fat (see Breast Reconstruction).

My colleagues and I have performed thousands of these surgeries and our cosmetic outcomes just keep getting better and better (see Gallery). Today reconstructed breasts almost always look better than the original ones. There have been several occasions when I performed a yearly breast examination on one of my prophylactic patients and had to do a double take when I realized the tissue I was feeling was an implant or fat and not breast tissue. The final result after prophylactic mastectomy and reconstruction can look and feel so real they can even fool an “expert”.