Chapter 69: Surgical Strategies for Breast Cancer Risk Reduction

INTRODUCTION

Surgical prophylaxis remains the most effective means to prevent breast cancer. Strategies for risk reduction include bilateral prophylactic mastectomy (BPM), contralateral prophylactic mastectomy (CPM), and prophylactic bilateral salpingo-oophorectomy (PBSO). BPM is performed for risk reduction in women who have not been diagnosed with cancer. In contrast, CPM is performed in patients with a diagnosis of unilateral breast cancer for risk reduction of contralateral breast cancer.¹ Current guidelines for prophylactic mastectomy (PM) include patients with BRCA1/2 mutations, other predisposing gene mutations, strong family history with no demonstrable mutation, and prior mantle radiation for Hodgkin’s lymphoma, all of which confer a significantly higher risk for breast cancer than for the general population.^2,3 Discussion of risk-reduction procedures is complex and should be individualized to ensure the best oncologic and psychosocial outcomes for each patient.

The first report of PM was described by Bartlett in 1917.⁴ By the 1970s, it was estimated that approximately 600 to 700 prophylactic mastectomies were being performed annually in the United States.^5,6 However, a number of retrospective studies have indicated that the incidence of both CPM and BPM has increased significantly in recent years.^7-12

SURGICAL PROCEDURES FOR RISK REDUCTION

Background

Subcutaneous mastectomy was first described by Rice and Strickler in 1951.¹³ Typically, a rim of normal breast tissue was left underneath the nipple-areolar complex (NAC) to give the remaining chest wall a more natural appearance before the development of modern breast reconstructive techniques.^14-16 However, it became apparent with long-term follow-up that subcutaneous mastectomy did not adequately prevent high-risk patients from developing breast cancer.^17,18 With the discovery of BRCA1/2 gene mutations, simple, or total, mastectomy (defined as removal of the NAC, all grossly evident breast tissue, and preservation of the axillary contents) was felt to provide greater risk reduction.^15,19,20

Skin-Sparing Mastectomy

Due to significant improvements in breast reconstructive options, skin-sparing mastectomy (SSM) is currently the most common type of mastectomy performed for risk reduction.¹⁶ First described by Toth and Lappert in 1991, this procedure involves removal of all breast tissue and the NAC while maintaining the skin envelope of the breast.²¹ The main advantage of this procedure is an improved cosmetic outcome as the native skin envelope allows for better appearance, position, and shape of both prosthetic and autologous-tissue reconstructions.^21-23 When it was initially introduced, a major concern was the amount of residual breast tissue remaining on the longer skin flaps, inframammary fold, and axillary tail.²⁴ Barton et al²⁵  evaluated this by comparing 27 cases of mastectomy with minimal skin excision and variable treatment of the NAC in high-risk patients to 28 cases of modified radical mastectomy (MRM). They biopsied six sites along the chest wall, in the axilla, ...