Breast Cancer Awareness Month: What is mastectomy and how does it work? Experts say it cannot eliminate risk
Some women who are at a very high risk of developing breast cancer choose to have surgery to remove one or both breasts to reduce the risk. This is known as prophylactic or preventive mastectomy. All women are at risk of breast cancer just by being female and advancing in age. But some factors increase the risk significantly, such as inherited changes (mutations) to certain genes, BRCA1 and BRCA2.
There are other factors such as a family history of breast cancer, radiation therapy to the chest as part of treatment for another cancer before the age of 30 and if a woman already has had cancer in one breast, among others. However, being identified as having high risk does not imply that a woman is certain to get breast cancer.
Deciding what to do with the knowledge that you are at high risk of breast cancer is a complex and time-consuming process. Taking time to weigh the pros and cons is a critical part of the decision-making process. According to experts, it is important to talk to the doctor before deciding on a mastectomy and learn about options so that women can understand if it is right for them and how much it may benefit them versus the likelihood of risks and side effects.
What are the different types of mastectomy?
There are several different types of mastectomies, based on how the surgery is done and how much tissue is removed.
Double mastectomy: Also, known as a bilateral mastectomy, it refers to the removal of both breasts. Hollywood actress Angelina Jolie, for example, underwent double mastectomy several years ago.
Total/simple mastectomy: In this procedure, the surgeon removes the entire breast, including the nipple, areola and skin. Some underarm lymph nodes may be removed depending on the situation.
Modified radical mastectomy: Combines a simple mastectomy with the removal of the lymph nodes under the arm
Skin-sparing mastectomy: Most of the skin over the breast is left intact, and only the breast tissue, nipple and areola are removed. Many women prefer skin-sparing mastectomy because it offers the advantage of less scar tissue and a reconstructed breast that seems more natural. But it may not be suitable for larger tumors or those that are close to the surface of the skin.
Nipple-sparing mastectomy: It is the removal of as much breast tissue as possible while leaving the nipples intact. It is more often an option for women who have a small, early-stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple.
Contralateral prophylactic mastectomy: Some women who have already been diagnosed with breast cancer elect to have the other breast removed at the time of the surgery to remove the breast with cancer. This operation, known as a contralateral prophylactic mastectomy (CPM), can help lower their risk of developing a second breast cancer.
To what extent does mastectomy reduce the risk of breast cancer?
According to health experts, for women at high-risk, removal of both breasts reduces the risk of breast cancer by 90% or more. However, it cannot eliminate the risk of getting breast cancer. This is because it is not possible to remove all of a person’s breast tissue, even with a mastectomy. The breast tissue remaining in the body can still develop breast cancer.
“Even with total mastectomy, not all breast tissue that may be at risk of becoming cancerous in the future can be removed. The chest wall, which is not typically removed during a mastectomy, may contain some breast tissue, and breast tissue can sometimes be found in the armpit, above the collarbone, and as far down as the abdomen — and it is impossible for a surgeon to remove all of this tissue,” explains the National Cancer Institute (NCI).
According to the American Cancer Society, CPM might be a good option for women who also have other factors that increase their risk of getting another breast cancer, such as a BRCA1 or BRCA2 mutation or a strong family history of breast cancer. “But for women without a family history of breast cancer or other risk factors, the benefit of a CPM is less clear. Having breast cancer does raise your risk of getting cancer in the other breast, but this risk is still usually low, and many women overestimate this risk. And while CPM lowers the risk of getting cancer in the other breast, for most women it does not increase the chances of living longer,” it suggests.
What are the risks?
For some women, the benefits of such a serious preventive step outweigh the risks, for personal and medical reasons. But this may not be true for every woman. As with any other major surgery, mastectomy may have potential complications or harms, such as bleeding, infection, or pain.
The side effects of mastectomy can depend on the type of mastectomy and can include pain or tenderness of the surgery site, swelling at the surgery site, limited arm or shoulder movement, numbness in the chest or upper arm, the buildup of clear fluid in the wound, and buildup of blood in the wound. Another side effect could be nerve pain (sometimes described as burning or shooting pain) in the chest wall, armpit, and/or arm that does not go away over time, and it is also known as post-mastectomy pain syndrome or PMPS.
Anxiety or disappointment about changes to one’s appearance is also possible. “It can affect a woman’s psychological well-being due to a change in body image and the loss of normal breast functions. Although most women who choose to have this surgery are satisfied with their decision, they can still experience anxiety and concerns about body image. The most common psychological side effects include difficulties with body appearance, feelings of femininity, and sexual relationships. Women who undergo total mastectomies lose nipple sensation, which may hinder sexual arousal,” says NCI.
What to expect after a mastectomy?
It is important to talk to your doctor about what to expect. Women having a mastectomy usually stay in the hospital for 1 or 2 nights and then go home. How long it takes to recover from surgery depends on what procedures were done, and some women may need help at home. Most women should be fairly functional after going home and can often return to their regular activities within about four weeks.
Recovery time is longer if breast reconstruction was done as well, and it can take months to return to full activity after some procedures. Some women might get other treatments after a mastectomy, such as hormone therapy to help lower the risk of cancer coming back. Some may also need chemotherapy, or targeted therapy after surgery. If so, radiation therapy and/or hormone therapy is usually delayed until the chemotherapy is completed.
Are there other options for reducing risk of breast cancer?
Maintaining a healthy lifestyle, regular exercise, limiting alcohol use and avoiding hormone therapy during menopause may reduce the risk of breast cancer. Breast-conserving surgery (BCS) -- in which only cancerous tissue, plus a rim of normal tissue (tumor margin) is removed -- could be an option. According to ACS, despite equivalent survival when combined with radiation, BCS-eligible patients are increasingly electing mastectomy for many reasons, including reluctance to undergo radiation therapy, fear of recurrence, and desire for symmetry.
“The fact is that in most cases, mastectomy does not give you any better chance of long-term survival compared to BCS. Studies following thousands of women for more than 20 years show that when BCS is done along with radiation, the outcome is the same as having a mastectomy,” says ACS. It adds, “For women who are worried about breast cancer coming back, it is important to understand that having a mastectomy instead of breast-conserving surgery plus radiation only lowers your risk of developing a second breast cancer in the same breast. It does not lower the chance of the cancer coming back in other parts of the body, including the opposite breast.”
Experts also say that if a woman is at increased risk, they might consider taking medicines that can help lower their risk after talking to the doctor. The doctor may suggest more intensive screening for breast cancer, which could include starting screening at an earlier age or having other tests besides mammography.
Breast reconstruction surgery after mastectomy
Women who undergo mastectomy may have breast reconstruction, either with a saline or silicone implant, tissue from another part of the body, or a combination of the two. A woman considering breast reconstruction should discuss this option with her breast surgeon before the mastectomy to coordinate the treatment plan with a plastic surgeon, recommend experts. This allows the surgical teams to plan the treatment that is best for you, even if you wait and have the reconstructive surgery later.