Benefits of Preventive Surgery

The younger you are when you have preventive surgery, the greater the potential benefit. Breast cancers linked to abnormal breast cancer genes usually occur at younger ages than the more common, age-related breast cancers. Ovarian cancer can occur at an early age, but is about as big a risk for older women. So the earlier you remove the breasts, ovaries, or both, the more likely you are to avoid one of these early cancers before it has a chance to form.

The type of abnormal breast cancer gene a woman has seems to influence how much risk reduction she gets from preventive ovary removal. A 2008 study by researchers at Memorial Sloan-Kettering Cancer Center found that in women who had an abnormal BRCA1 gene, removing the ovaries was more beneficial for lowering ovarian cancer risk than lowering breast cancer risk. In women who had an abnormal BRCA2 gene, removing the ovaries was more beneficial for lowering breast cancer risk than ovarian cancer risk.

Of course, you need to balance the potential benefits of preventive surgery against the side effects. For example, family planning issues may be a concern, whether you've already had children or want to have children in the future. Talk to your doctor or genetic counselor about the risks and benefits of waiting to have preventive surgery until after you've had children.

Also remember that no procedure — even surgery — totally eliminates the risk of cancer. Even when a breast or ovary has been removed, cancer can still develop in the area where it used to be. Close follow-up is necessary for all women, even after prophylactic operations.

Can prophylactic surgery benefit older women at high risk for breast cancer?

If you are at high risk for breast cancer, the potential benefit of preventive surgery gets smaller as you get older. There are several reasons for this:

• Your risk of other medical conditions that can affect how long you live, such as diabetes, heart disease, and smoking-related diseases, goes up.
• Your risk of developing a breast cancer that's related to a genetic abnormality tends to decrease.
• As a separate issue from your health, the older you are, the shorter your remaining life expectancy is. So there is a lessened need for a long-term protection strategy.

But these are only generalities, and some or all may not apply to you. For example, you may be a 65-year-old woman with a family member who just found out she has a BRCA1 genetic abnormality. Testing revealed that you have the same abnormality, and your doctor is recommending preventive removal of the ovaries to lower the risk of ovarian cancer. Your risk is significant, even as an older woman, and ovarian cancer is hard to detect early. Your doctor may also recommend hormonal therapy (anti-estrogen therapy) to reduce your risk of breast cancer, instead of preventive breast removal. And of course, no matter what your age, if you are at high risk of breast cancer, close monitoring is very important.

Can prophylactic surgery benefit a woman who has already been treated for breast cancer?

If you've already had breast cancer, you may be wondering whether prophylactic surgery could have any benefit for you. The value depends to a large degree on your age, your overall medical health, and whether you have any other illnesses, as well as the stage and kind of breast cancer that you have had.

A woman who does not have an abnormal breast cancer gene and has been treated for early-stage breast cancer has a low risk of the original cancer coming back and has a long life expectancy. But if you've been diagnosed with breast cancer and also have a breast cancer gene abnormality or strong family history of breast cancer without a proven genetic abnormality, you are at increased risk of developing a new, unrelated cancer over the rest of your lifetime. The risk is about 2-5% per year, depending on the kind of gene abnormality in your family, plus other factors that might affect how that gene behaves. Over 10 years, this translates to a risk that ranges from 20% to 50%. In this case, preventive surgery may be of value to you.

If you've had breast cancer without a significant family history or any proven genetic abnormality, then you are still at increased risk of getting another unrelated breast cancer in the future. But your risk will be lower than that of a woman with an inherited predisposition to getting breast cancer because of an abnormal gene. Your risk is about 1% per year, which is about 10% over 10 years. Since your risk is lower, you will benefit less from prophylactic surgery.

But if you have been treated for moderate- to late-stage breast cancer, the risk of the cancer coming back in the same breast may be greater than the risk of developing a new, unrelated breast cancer. In that case, prophylactic surgery may offer only limited benefit. Before you can make a solid decision, you need to know the pros and cons of your individual situation.

For example, if you're 70 years old and were diagnosed with stage III cancer (a large cancer with many lymph nodes involved or skin involvement), the main focus of your care is on treating that cancer. The risk of the stage III cancer now is much greater than the theoretical risk of a possible new, unrelated cancer. Once your main cancer therapy is over, your doctor may make recommendations to deal with your cancer coming back as well as new potential cancers in the future.

If you are interested in the role of preventive surgery after treatment for breast cancer, talk to your doctor and genetics counselor about the pros and cons for your specific situation.

Benefits of prophylactic removal of the ovaries

Early-stage ovarian cancer is harder to find than early-stage breast cancer. In addition, there are fewer good strategies for significantly reducing the risk of ovarian cancer. Therefore, if you are at high risk for ovarian cancer, you might decide to have only your ovaries removed as a protective measure.

Memorial Sloan-Kettering Cancer Center recommends prophylactic removal of the ovaries for women with a known BRCA1 or BRCA2 abnormality at high risk for breast cancer as soon as they have completed childbearing or by age 45, whichever comes first. Sloan-Kettering is less likely to recommend prophylactic mastectomy, because effective medications, such as tamoxifen, are available to reduce breast cancer risk, with the promise of new medications soon to come. Sloan-Kettering also advises a more intensive screening program: twice a year, alternating detection methods. So you might have a mammogram in January and an MRI in July.

You have choices

All women with a breast cancer gene abnormality need frequent careful surveillance. Beyond that, no single course of action is right for all women with BRCA1 and BRCA2 abnormalities. Depending on your preferences and life circumstances, you may choose one or a combination of these options, at the same or at different times:

• frequent careful surveillance
• medication with or without surgery
• prophylactic removal of the breasts
• prophylactic removal of the ovaries (along with the fallopian tubes)

These are choices you need to make by considering all the information that applies to you, with the help of genetic counselors, doctors, psychological counselors, other health care professionals as needed, and loved ones.