November 23, 2012 | by Roberta Nichols
Miss America contestant Allyn Rose and TV host Sharon Osbourne have both made headlines recently for their decisions to undergo double mastectomies. Osbourne has already had both breasts removed; Rose will undergo surgery after the pageant in January. Neither one had breast cancer.
But Osbourne, who had already undergone treatment for colon cancer, had learned that she carried a gene known to increase the risk of breast cancer. And Rose, whose mother died of breast cancer linked to a rare chromosomal disorder, had learned that she was a carrier of that same disease.
Rose and Osbourne garnered attention for their decisions because neither one had been diagnosed with breast cancer. But their decision is one that more women across the country are making about breasts unaffected by breast cancer.
Prophylactic, or preventive, mastectomy often follows a test in which a woman with a strong family history of breast or ovarian cancer undergoes a test for genetic mutations linked to those diseases. The presence of the mutation means that she has up to an 85 percent chance of developing breast cancer during her lifetime.
Such surgeries can reduce the chance of developing breast cancer in moderate- and high-risk women by up to 90 percent, according to the National Cancer Institute. But it’s no guarantee.
For an increasing number of women already diagnosed with breast cancer in one breast, the decision to remove the healthy breast removed, known as a contralateral prophylactic mastectomy, seems like a wise one.
During the past decade, the rate of women undergoing contralateral prophylactic mastectomy (CPM) has increased dramatically, says Laura L. Kruper, M.D., director, Cooper-Finkel Women’s Health Center and Chief of Breast Cancer Service at City of Hope. She designed a study to find out why women choose to undergo such procedures.
She and her colleagues sent questionnaires to women who underwent mastectomies at City of Hope from 1972-2011 and still receive follow-up care there. They were asked their reasons for undergoing a prophylactic mastectomy or choosing not to have one, and for only undergoing a unilateral (one-sided) mastectomy. Most of the women in the study had been diagnosed with breast cancer.
Those choosing CPM tended to be younger, married, and Caucasian with a higher education level, Kruper, an assistant professor and surgeon in the division of general oncologic surgery at City of Hope told HemOnc Today.
Researchers also found that women who chose to have a prophylactic mastectomy tended to have a family history of breast cancer or a genetic mutation (BRCA 1 or 2).
“It makes sense that younger women and women with a family history are more likely to choose PM since there is a higher risk of recurrence in these two groups,” said Kruper. Patients with a family history of breast cancer were three times as likely to undergo CPM compared to those with no family history, she said.
With BRCA genetic mutations, the risk of developing cancer rises to 85% in one's lifetime, according to Kruper. “There are many other women who have a fairly extensive history of breast cancer who might not carry a BRCA genetic mutation but are found to be at high risk of developing breast cancer based on predictive tools like the Gail Risk model or BRCAPRO.”
On the other hand, the risk of contralateral breast cancer is low for many women, yet patients’ perceived risk is much higher, says Kruper.
Though this study identified some of the demographic factors influencing a woman’s decision to have PM, it also underscored a more fundamental question: what’s the right medical choice in these cases? In the women with genetic mutations, the recommendation is for prophylactic mastectomies before cancer has a chance to strike. For women diagnosed with breast cancer and no genetic mutation, the recommendation about CPM is based on many factors including age of the patient, family history, and individual choice.
“I think further study is needed to tease out societal influences on women’s choices and how we, as physicians, can best counsel women about the true level of risk of future cancers,” Kruper said.