Preventive Surgery

Q1: Who should be offered a bilateral prophylactic mastectomy? We discuss prophylactic mastectomy with BRCA1/2 mutation carriers who are both affected and unaffected. We do not consider mastectomy a mandate, but rather an option. In the US, the use of contralateral mastectomy in BRCA1/2 negative women with unilateral breast cancer is increasing. My personal belief is that too many women are having this done without compelling reasons to do so. It is generally covered by insurance, so that is not a hold-up. I spend quite a bit of time trying to counsel my patients based on their age, treatment (for example if they are receiving endocrine therapy which will decrease their risk of contralateral breast cancer), family history, and stage of their primary tumor. Despite this, I do think that women often overestimate their risk. In particularly high-risk, BRCA1/2 negative families, prophylactic mastectomy in unaffected women is discussed. There are no set guidelines for this, but I believe that the families should have at least a 30% prior probability of a BRCA1/2 mutation.