BRCA Preventive Surgery: Owning Your Choices

BRCA positive is a weighty diagnosis. Right now, you have a big decision to make. While carrying this specific genetic marker can represent up to a 70% chance of developing breast cancer over your lifetime, it’s never known for certain. You can choose to wait and undergo exhaustive lifetime screening, hoping you never develop breast cancer. Or you can get a BRCA preventive surgery, a prophylactic mastectomy, to proactively reduce your risk. Neither decision is right or wrong; It’s just a matter of personal choice and what your medical provider thinks is best.

The Two Approaches to BRCA Positivity

I briefly covered the two approaches to BRCA positivity in the intro above. You can wait and see or you can have a prophylactic mastectomy and breast reconstruction.

If you choose to go the noninvasive route, your healthcare team will likely start by setting up a monitoring schedule. That schedule will outline the frequency and types of screenings you will undergo regularly. That might include increased clinical breast exams, mammograms, and breast MRIs. These imaging studies will allow your doctor to catch any potential breast abnormalities in their most treatable stage.

That is the wait-and-see approach in a nutshell. If you develop breast cancer, you’ll move onto the mastectomy, radiation, and chemotherapy stages of treatment. However, your mastectomy and reconstruction may be more complicated because cancer is already present—and radiation and chemotherapy, which can sometimes be indicated once cancer is identified, may also cause changes to your skin. And even if cancer develops in one breast, there is now the question of how to manage the contralateral breast in the BRCA patient with cancer.  To avoid this uncertainty, some women opt for BRCA preventive surgery.

What You Need to Know About BRCA Preventive Surgery

BRCA preventive surgery involves a mastectomy (to prevent breast cancer) and sometimes removal of the fallopian tubes and ovaries (to prevent ovarian cancer). While it’s not a guarantee, the mastectomy can reduce your risk of getting breast cancer by up to 90%. The extent of the surgery will depend on the results of your genetic counseling and your healthcare team’s recommendations.

There are three basic approaches to mastectomies:

• Bilateral prophylactic skin sparing mastectomy: When considering a bilateral prophylactic mastectomy, the main goal is to significantly reduce the risk of developing breast cancer. This procedure surgically removes both breasts, including all breast tissue, nipples, areolas, and lobules. By removing all the breast tissue, the risk of developing cancer in the future is substantially reduced.

• Bilateral prophylactic nipple-sparing mastectomy: A nipple-sparing mastectomy can also be considered a preventive option for individuals at a lower risk of developing breast cancer or who have been deemed suitable candidates. By sparing the nipple and areola during the mastectomy, this approach allows for a more natural appearance after reconstruction.  There are oncologic and anatomic reasons why nipple sparing mastectomy might not be ideal, but in a purely prophylactic case, a preliminary breast lift/reduction to reposition the nipple areola complex in anticipation of preventative nipple sparing mastectomy can be planned.

• Contralateral mastectomy: Although contralateral mastectomy is often  performed as a preventive measure alone when someone is diagnosed with one sided breast cancer, it is routinely recommended for BRCA positive women who develop breast cancer in one breast and are concerned about their overall breast cancer risk.

While the mastectomy procedure itself is intricate, it is not the most challenging aspect of BRCA preventive surgery. The reconstruction phase is the priority to end up with an aesthetically satisfying result. Two surgical approaches, anticipated one-stage and staged reconstruction, are commonly employed for breast reconstruction after mastectomy.

In anticipated one-stage reconstruction, patients undergo breast reconstructive surgery concurrently with their mastectomy. Frequently, this is done with a nipple-sparing mastectomy, which allows the plastic surgeon to immediately reconstruct the breast mound while preserving the natural appearance of the breasts. This approach is common among those undergoing preventive mastectomies due to BRCA positivity.  Direct-to-implant or natural tissue reconstruction, such as the DIEP or TRAM flap, are common examples of immediate.  Even when anticipated one-stage surgery is planned, revisional procedures to tweak the surgical result may be recommended in the months after the primary surgery, which is considered an integral part of the reconstructive process.

On the other hand, staged reconstruction is often considered after a skin sparing mastectomy, where there may be less skin and tissue to work with. After the mastectomy,  a tissue expander or permanent implant may be inserted beneath the preserved skin. Over time, the expander is gradually filled to stretch the skin and create space for the final implant. Once the desired expansion is achieved, the temporary expander is replaced with a permanent implant, and in some cases, nipple and areola reconstruction is performed.

Staged reconstruction allows for gradual adjustment of the breast’s appearance and minimizing tension on the surgical site. While it requires multiple surgeries and a longer timeline, it often results in natural-looking outcomes.

In either situation, consulting with a plastic surgeon before undergoing BRCA preventive surgery is advisable. Your plastic surgeon can guide your procedure to help you obtain the most authentic and natural outcomes. It is reasonable to consult with a Plastic Surgeon as a first step following diagnosis of a genetic susceptibility to breast cancer, so the overall understanding of aesthetic outcomes can be detailed in the process of choosing next steps.  The Plastic Surgeon can refer a patient directly to the Breast Surgeon with the particular skills to perform the mastectomy at the time of reconstruction. At times, hearing about mastectomy from the Breast Surgeon, before understanding the reconstructive options available can be disheartening and a barrier to fully informed shared decision making regarding preventative management of the breasts.