Q&A: Although preventive mastectomies rise, procedures still not often recommended
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For many oncologists, the use of mastectomy to treat breast cancer cases can be a difficult subject to approach with patients.
However, in recent years a rise in the use of preventive mastectomies has driven an upward trend of mastectomies overall, even though a preventive procedure is rarely recommended.
Healio spoke with Katharine Schulz-Costello, DO, a surgical oncologist at City of Hope, to learn more about what’s driving the rise in mastectomies and how she addresses the procedure with her patients.
Healio: What considerations go into recommending mastectomy for breast cancer?
Schulz-Costello: Tthere’s a variety of ways patients can present with breast cancer. Sometimes cancer is found on screening imaging. Sometimes it’s found as an incidental finding for workup of another problem. And sometimes patients or their provider can find something on an exam.
One of the bottom lines for all things having to do with breast cancer is it’s very individualized to the patient. And it’s very individualized to the disease process. It's also a multidisciplinary decision. Often when I counsel a patient who’s been diagnosed with breast cancer, I’m the first person who they see. And my No. 1 goal is to see if they’re a candidate for a breast-conserving therapy versus if a mastectomy is the safer option.
If either is an option, then it’s a more nuanced, kind of extensive discussion. And I typically invite patients to also meet with my colleagues in plastic surgery and radiation oncology, because a lot of the treatment goes hand-in-hand, also with their expert care. Some patients aren’t candidates to get a lumpectomy and mastectomy is their only option, and I'll have them meet with plastic surgery to discuss reconstructive options.
And even sometimes a radiation doctor, if I anticipate post-mastectomy radiation will be needed. And if they're a candidate for both a lumpectomy and mastectomy, we kind of go through the pros and cons of both of those surgeries.
Healio: What kind of patients are more likely to have a mastectomy recommended?
Schulz-Costello: The patients who lean toward a mastectomy are those who have a large volume of cancer. Sometimes there are certain cancers where the extent of resection will kind of render a cosmetic deformity that would not be acceptable over time. If more of the breast has cancer than less of the breast, it's hard to save 20% of a breast. The more definitive thing is a mastectomy.
Another subgroup where mastectomy can be considered more strongly is genetic mutation carriers. We are learning a lot all the time about genetics, meaning mutations that we may have inherited from our mom or dad — germline mutations — that can make us higher risk to get cancer. And, again, very nuanced and individualized. Some mutations carry a very high risk for getting cancer over the lifetime, and some mutations aren't as high of a risk.
For some of the mutations that have a high risk for getting cancer, patients can choose to have prophylactic or risk-reducing mastectomies to prevent them from getting cancer and, thus, cancer-related treatment. There are very few survival advantages to having risk-reducing surgery, but it's certainly an option. And as we get more information about genetic testing, I think it's a very reasonable option, for some patients who are high risk that they’re trying to prevent cancer-related treatment and getting cancer in the first place.
Sometimes we don’t find out somebody has a mutation until they’re diagnosed with cancer. And if it’s a high-risk mutation where they’re going to need a lot of follow-up or have a higher risk for getting cancer, mastectomy sometimes is also a more reasonable option. But lumpectomy is also still safe.
Healio: Are there subgroups where you do recommend a preventive mastectomy?
Schulz-Costello: Yeah, there’s no absolute indication or recommendation for me personally, or in any National Comprehensive Cancer Network guidelines, for anybody to get a routine prophylactic mastectomy. It's just something to be considered. And again, it's very individualized. If someone is 30 with a mom or sister who unfortunately got breast cancer at a young age, and they have a gene mutation, that’s a patient population that’s likely very reasonable to do a prophylactic surgery on, versus somebody who's 75 who it’s unlikely to help.
A principle in a lot of medicine is we don’t want to do any harm. So, if we're undergoing an elective operation, we need to be sure that the benefit of that operation outweighs the risks of it. Some of the risks of mastectomy are change — it’s a change to your physical appearance. You will feel and look different. And for some women, that’s why lumpectomy is a better choice. Less is more.
Some recent studies for patients with cancer have shown a survival benefit to lumpectomy and radiation over a mastectomy. So, we don't have all the answers, but for somebody with cancer, it certainly equals survival if they do a lumpectomy versus a mastectomy. A lot of women’s instinct is to do a mastectomy — because they’re just like, “Take them off. My life's more important than the breast.”
But the reality is their survival isn’t driven by their surgical choice. It’s actually driven by the type of cancer that they have. And that’s why women get to have a choice. And it’s somewhat nuanced in the discussion, because whenever there’s a choice, there are pros and cons to each arm. And in general, one area will speak to somebody and feel more comfortable for them. But that’s why seeing a radiation doctor and a plastic surgeon, we're making that decision as a team with the patient. We're not making that decision for the patient.
Healio: What are the trends in terms of quantity of mastectomies being performed?
Schulz-Costello: There's definitely an increase in the decision for bilateral mastectomy. And sometimes that’s because patients are younger — there are trends in celebrities, like social media. But the most important thing is thatpatients have a fair discussion, and don’t apply what someone they heard about did, because everybody’s cancer is very different.
Healio: How do you manage patients’ anxieties over mastectomy and what kind of support exists for them?
Schulz-Costello: Plastic surgery colleagues are really key to this discussion. Because, in a sense, a lot of the surgery I'm doing is to get rid of cancer, or do my best to maximally reduce their risk for cancer. But I typically describe reconstructive, as a journey. Sometimes it’s not a single surgery. Sometimes, patients have expanders and they need implants in the future, or they have implants and they need to have a revision.
Bodies can change over time. The reconstruction can change over time. There is a trend for going flat, so it’s called an aesthetic flat closure. There are online resources devoted to this, like NotPuttingOnAShirt.org. And that is where a woman chooses to have a mastectomy and have basically the best cosmetic outcome after the mastectomy, but have a flat chest. And that’s a great option for women, too.
A lot of patients, when they’re diagnosed with cancer, are really in a vulnerable, fragile state. So, I think nobody should make a decision in a single consult, or in a day. Our job as doctors is to educate patients. We want to teach them. They went from potentially not knowing anything about cancer to now making these nuanced decisions for themselves, and they never went to medical school.
Our job is to try to present information in an easy-to-understand way; have them meet with colleagues that are part of that decision-making. And then, a lot of times people talk about this with their family, with their friends. There’s always really excellent support groups in the community. For some of the physical aspect, I like to show patients a slideshow of it. It's called "My Informed Decision-Making" slideshow of before and after patients, just so they can have a realistic expectation. And this is common practice with all reconstructive plastic surgeons as well. But I think that's an important thing that people take time to make the right decision for themselves.
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