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          Breast Reconstruction Surgery Following Prophylactic Mastectomy: Get the Facts

          A woman's odds of developing breast cancer during her lifetime are about one in eight, according to American Cancer Society (ACS) statistics. However, for the small percentage (0.1 to 0.2 percent) of women who carry an altered version of the BRCA1 or BRCA2 genes — often referred to as "the breast cancer genes" — the lifetime risk of developing breast and/or ovarian cancer increases to between 40 and 85 percent.

          The good news is there is something these women at highest risk can do to reduce their chances of a breast cancer diagnosis. It's called a prophylactic mastectomy, or surgery to electively remove the breasts, and it may cut their risk of developing breast cancer by 90 percent. Additionally, some women may also opt for the prophylactic removal of their ovaries to lower their risk of ovarian cancer by the same percentage.

          Electing to voluntarily undergo a mastectomy before breast cancer diagnosis is not an easy decision to make. You will also be faced with the emotional dilemma that pits major invasive surgery against increased peace of mind that you may beat the cancer odds.

          Should You Undergo Breast Cancer Gene Testing?

          Normally, the BRCA1 and BRCA2 genes help prevent cancer by producing proteins that keep cells from growing abnormally. When a mutation of the genes occurs, however, they become the most common cause of hereditary breast cancer. These cancers typically strike younger women and are often bilateral (in both breasts), according to the ACS.

          Should you get tested? It depends. There is no standard recommendation right now. That said, women who had breast cancer at a very young age, as well as those with a strong family history of breast and/or ovarian cancer, may be referred to genetic counseling to determine if they should be tested.

          Genetic testing is usually advised for women with a family member who has had a positive BRCA1 or BRCA2 genetic test result; a male relative with breast cancer; or a family member on either side with both breast and ovarian cancer, bilateral breast cancer, or ovarian cancer.

          One ethnic group that should consider genetic counseling, regardless of their family history of cancer, is women of Eastern European Jewish (Ashkenazi) ancestry.

          Genetic Counseling Is a Must

          It is important to undergo professional genetic counseling prior to being tested for BRCA1 and BRCA2. The genetic counselor starts by collecting a detailed family and medical history and assessing your risk of developing cancer. He or she then reviews the risks and benefits of genetic testing with you so you can make an informed decision. This discussion should include the medical implications of a positive, negative or ambiguous test result, the psychological risks and benefits of genetic test results, and the risk of passing on the genes to offspring.

          Cost of Breast Cancer Gene Testing

          The cost of breast cancer gene testing can run up to thousands of dollars. Even with coverage, insurance policies vary widely on whether or not they cover genetic testing for breast cancer genes.

          Check first with your insurance company to confirm its policy regarding genetic testing for BRCA1 and BRCA2 mutations. Be aware that protecting the privacy of your medical information — particularly genetic test results — can be very important in light of future employment and insurance needs.

          Breast Reconstruction Options

          If you test positive for a mutation in the BRCA1 and/or BRCA2 genes and decide to undergo a prophylactic mastectomy, immediate breast reconstruction surgery can usually be performed to help restore the look and feel of your breasts, as well as your self-esteem.

          Several steps may be involved in breast reconstruction. First the breast mound must be recreated. Next, the nipple and areola are reconstructed, usually a few months later once the breast has healed. The nipple and areola are fashioned from transplanted tissue and/or medical tattooing.

          Breast reconstruction following prophylactic mastectomy usually involves using a balloon-like tissue expander that is placed under the skin and chest muscle. Through a valve in the expander, the surgeon injects saline (sterile salt water) over a period of several months, stretching the skin over the expander enough to accommodate a permanent breast implant.

          There are many types and shapes of breast implants. The two most common types are saline and silicone. Choosing the right breast implant for you is a decision best made in consultation with your plastic surgeon.

          An alternative to implants is using an autologous (from your own body) tissue transplant. Preferred donation sites include the belly, back and buttocks. If enough tissue is not available, an implant can be used to help rebuild the breast.

          Prophylactic mastectomy is a very effective way for women at high risk to decrease their chances of developing breast cancer, but it is not fail-safe. Breast cancer can still develop in the remaining envelope of skin that surrounded the breast. It is imperative that you and your doctor develop a customized follow-up plan to monitor and protect your breasts and overall health. This plan may include medications, physical exams, and radiographic and blood tests every six months.

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            Joseph A. Mele, MD, FACS

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            A.J. Khalil, MD

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