Do I Keep My Breasts?
Not the Only Option
While slightly more than 50% of women who learned that they carried one of the BRCA mutations opted for a double mastectomy in the Lancet study, it's clearly not the only option. Even when breast cancer does occur, tumors in women with BRCA mutations aren't any more virulent than cancers in other women, says Anne Blackwood, MD, an assistant professor of medicine and epidemiology in the division of hematology and oncology at the University of Pennsylvania Medical Center in Philadelphia. If the cancer is caught early, a simple lumpectomy -- where doctors remove the cancerous mass but leave the rest of the breast intact -- may suffice.
If other choices exist, then, why have so many women opted to have their breasts removed? Often the decision comes down to whether a woman can live with the knowledge that she has a good chance of developing breast cancer, says Linda Vahdat, MD, an assistant professor of medicine at Columbia Presbyterian Medical Center in New York City. "What matters is your level of fear," she says. "If you have a high level of fear, you probably should have a prophylactic [preventive] mastectomy. If you can put it behind you and go on with your life, you may want to do something else."
Women have to do what will give them the least amount of stress, says Vogel. Once they know about their elevated risk, some simply can't escape the gnawing fear. "Women have told me, 'I want them gone. Every day I wake up and wonder if today is the day I will develop breast cancer,' " he says.
But other women are loath to part with their breasts because their physical appearance and sexuality are so tied to their identity, Vogel says. For these women, breast reconstruction -- no matter how good the rebuilt breasts look -- may not be enough. "It's not the same as having a normal breast," he says. "You lose all sensation."
After the Surgery
While women who undergo preventive mastectomies greatly reduce their odds of breast cancer, there are other risks associated with the procedure itself, Vahdat says. General anesthesia can cause various complications, the most serious of which, in extremely rare cases, is death. There are also risks of blood clots and infection, especially with the longer surgeries needed to remove the breasts and reconstruct them with a woman's own fat tissue.
Since the breast cancer gene also increases the risk that a woman will develop ovarian cancer, she may choose to have her ovaries removed as well -- which sends her into immediate menopause. This means her risk of heart disease and osteoporosis will rise unless she begins hormone replacement therapy. The good news in that circumstance, Vogel says, is that these women don't have to worry about the potentially increased risk of breast or ovarian cancer that goes along with such therapy.