Women with gene mutations associated with a high risk of breast cancer should consider the possibility of bilateral prophylactic mastectomy to reduce the risk of developing the disease or mastectomy if diagnosed with breast cancer. These are the main conclusions of a recent review on the subject published in the Journal of the American Medical Association (JAMA).

When should a prophylactic mastectomy be considered?

Some women have a very high risk of developing breast cancer compared to the general population. The chances of getting sick can actually reach up to 70% and are mainly associated with the presence of pathogenic mutations in certain genes. The best known are BRCA1 and BRCA2 genes, but there are others such as Pten, CDH1, STK11 and Palb2. The risk of developing breast cancer is also high in women who have undergone chest radiotherapy before the age of 30 (eg young patients undergoing lymphoma treatment).

Preventive interventions can be offered to all these women. There are two strategies that can be used: the first is the bilateral prophylactic mastectomy, which is associated with a reduced risk of breast cancer 90% or more with a remaining risk of 1 to 2%. The second is the so -called active monitoring with very close preventive checks. In this second case, the risk of breast cancer remains, but the likelihood of tumor detection increases when it is still at an early stage, so treatable. Active monitoring includes, in particular, stricter control with a specialized breast-mastist surgeon, for example with ultrasound every six months and mammography and magnetic resonance imaging once a year. In addition, the possibility of monitoring with low dose of tamoxifen and lifestyle intervention (adequate nutrition and regular physical activity) may be considered.

However, often the psychological management of active monitoring is not easy, not all women are able to accept it. Very young women generally prefer to resort to prophylactic mastectomy because it almost completely reduces the risk of developing cancer, while monitoring and not surgery allows for early diagnosis of breast cancer (secondary prevention), but not primary prevention.

In any case, the choice of one approach instead of the other must be given by taking into account the mutated genes and the positive family history, so a personalized risk assessment is necessary.

For those at high risk, prophylactic surgery is a major possibility of reducing the probability of 90%. Rare cases of failure are associated with the appearance of neoplasms that affect breast residues that have not been fully removed. This is one of the reasons why it is very important to have surgery in centers specialized in this type of surgery and by breast surgeons with experience in breast surgery.

Prophylactic mastectomy should be oncologically correct and have a very good aesthetic effect.

How important is the presence of an interdisciplinary team?

It is necessary to incorporate the skills of various specialists before that surgery. Before undergoing bilateral prophylactic mastectomy, the woman should be aware of the disadvantages and advantages of this choice. The disadvantages are the change in breast feel, and that breastfeeding is not possible if she wishes to have children. There are many advantages and positive aspects: there is the advantage of removing the stress of exams, gaining greater psychological satisfaction and, often, even aesthetic improvement after the mastectomy with immediate rehabilitation.

At what age should the surgery be done?

The ideal time to perform bilateral prophylactic mastectomy should always be personalized, also taking into account the type of mutation, family history and age of the first possible breast cancer diagnosed in the family. Time can vary depending on the planning and needs of each woman. There are women, for example, who first decide to have a child, breastfeed and then undergo mastectomy.

After the age of 70, the choice of prophylactic surgery is less strict and the woman may decide to have close imaging checks. The need for a young woman is greater because she has all her life ahead of her and is easier to make a decision. Young women are much more determined and almost all of my experience they choose the bilateral mastectomy. A 70 -year -old woman, even if she finds out that she has a genetic mutation, more difficult to decide to do a condom mastectomy. Members of her family must undergo a transition for gene tests. The surgical choice should always be personalized and framed, reminding that it reduces the risk of breast cancer by more than 90%.

If breast cancer is diagnosed, when is the unilateral mastectomy?

The unilateral preventive mastectomy, that is, the removal of healthy breasts since the other breast is infected with cancer, is a practice that should be taken into account in women who develop breast cancer and are carriers of gene mutations (for example BRCA1 and 2, PTEN, PTEN, PTEN).

When dealing with a young girl who has been diagnosed with breast cancer or a woman under 45 who has a strong family history or has triple negative cancer, genetic testing should be performed for mutations. In these cases, genetic testing must be urgently, because its outcome can provide useful information to decide which intervention should be done. If there is no vegetative series mutation, the possibility of conservative surgery may be considered.

On the contrary, if the woman is a carrier of genetic lesions predisposed to cancer, both the mastectomy of the affected breast and the unilateral preventive mastectomy may be examined. It is very important to design all these actions in advance and this is one of the reasons why we must have an interdisciplinary approach. It has been observed that many women who do genetic testing before surgery then choose the mastectomy not only of the sick breast but also of healthy breast. For many women, the ultimate goal is to reduce the risk of cancer experience again, regardless of the prognosis associated with initial cancer.

What are the most up -to -date techniques for prophylactic mastectomy and mastectomy for breast cancer?

There have been times when my patients are very excited to say Mrs. Galanou no one in the summer have realized that we have done a mastectomy with immediate rehabilitation and many think we have done plastic surgery for aesthetic reasons. A patient from Crete told me that even the radiologist himself understood at first glance that there had been a mastectomy with rehabilitation. I can’t hide my emotion with the satisfaction of my patients. Since 2013 my specialization in Breast Surgical Oncoplasty at the European Oncology Institute Regina Elena Irccs Clinical Trial Center in Rome and my collaboration for many years as a breast surgeon with the excellent international renowned team of Breast Unit under the direction of Prof. Breast oncology with state-of-the-art technology. Mastectomy is now immediately rehabilitated using inserts, without expiration date, such as polyurethane. Pioneer and leader of this technique is Prof. Roy de Vita. Also the restoration can be done, if possible, and above the major thoracic muscle. The surgeon must have the right know -how and experience in these techniques to have the best results. For each patient the choice of surgical technique and inserts is personalized.

In small and medium breasts the mastectomy can be done robotically using the Robot Da Vinci. Also mastectomy can be done and endoscopically. In both cases the woman has no scars on the breast, instant rehabilitation with inserts in the same surgery at the same time and the nipple is maintained, since the rapid biopsy is negative for malignancy.

Robotic oncological surgery applied to mastectomy – breast surgical removal – enables the nipple -heaver complex, skin and subcutaneous flap containing the surface blood vessels, healthy tissues, and minimal tissue,

The use of the robot during these procedures facilitates proper removal of areas away from the skin incision to enable increased surgical accuracy, with a better depiction of anatomical structures and maintaining healthy tissues.

This technique allows us to have a very positive impact on aesthetic effect and postoperative quality of life.

The goal of minimally invasive robotic surgery is to achieve higher technical and aesthetic results compared to classical surgery while maintaining the same oncological principles as typical mastectomy.

Summarizing, now with modern breast surgery techniques using the most advanced technology for bloodless surgery, the result is that the patient has a quick recovery, immediate return to her daily life with a very good oncological and aesthetic effect.