Dr. Kirstein of MSKCC Answered Questions About Surgical Treatment of Breast CA.

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Mastectomy in BRCA + individuals, early and late stage breast cancer and the role of neo-adjuvant chemotherapy.

Ask the Expert About Surgical Treatment of Breast Cancer

I read recently that the trend toward breast conservation has reversed and more women elect mastectomy yet they are less satisfied over the longer term? Is this true and why the increase in mastectomy?

While the choice for double mastectomy has been increasing, the overwhelming vast majority of women still choose breast conservation for the management of their breast cancer. Long term studies have shown that generally people are happy with the surgery they choose, especially since there is no difference in survival based on the surgery. While there is no one reason for the increase in double mastectomy, possibilities include the popularization in the media and lack of understanding that the double mastectomy does not increase survival or need for chemotherapy.

If you have newly diagnosed stage 4 breast cancer that has spread to the bones is it necessary to undergo a mastectomy?

There are no studies to date that have shown a survival benefit to performing surgery for Stage 4 breast cancer. Usually surgery is limited to removing disease in the breast that is growing out of control and becoming a wound care issue. However, there are very good non-surgical treatments for Stage 4 breast cancer, and those are more appropriate.

Should women who are not BRCA + ever consider a double mastectomy to prevent breast cancer?

Women who are BRCA positive have a 60-90% lifetime risk of getting breast cancer. However, women without a BRCA mutation only have a 12.5% chance of getting breast cancer. That means 87.5% of those women will never get it. Studies have shown that even if a woman without a BRCA mutation gets breast cancer, the risk of getting another breast cancer in the other breast is very minimally elevated over that 12.5%. Removing the healthy breast in not considered a medical recommendation, since it isn’t really preventing what is already a low risk occurrence.

If you have breast implants do you need to get a mammogram?

Even with breast implants annual mammograms do need to be performed, since women with implants are still at risk of developing breast cancer. There are special ways to image the breasts with implants, and mammograms are the gold standard in the screening of breast cancer.

Who should get neo-adjuvant chemotherapy before surgery?

Guidelines suggest that neo-adjuvant chemotherapy should be given to women with breast cancer in their lymph nodes, and those who have tumors that are more than 2 cm and are triple negative or HER2 positive. Also, patients whose tumor is large compared to their breast size but who want breast conservation and will need chemotherapy as part of their treatment plan should consider neo-adjuvant chemotherapy to increase the rate of breast conservation.

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This Ask the Expert Series is made possible through support from the Personalized Medicine Foundation, CancerConnect and the Memorial Sloan Kettering Cancer Institute. Ask the Expert content and programs are not intended to be a substitute for healthcare professional medical advice, diagnosis, or treatment. Information should be used to further an individuals discussion with their managing healthcare team or providers. Speak to your healthcare provider about any questions you may have regarding your health.

Dr. Laurie Kirstein is a surgeon who cares for people with breast cancer at Memorial Sloan Kettering Cancer Center. She has an interest in oncoplastic procedure to ensure positive cosmetic outcomes as well as expertise in the screening of individuals for breast cancer. After attending SUNY Health Science Center at Brooklyn Dr. Kirstein completed a General Surgery Residency at Albert Einstein College of Medicine and a Fellowship in Breast Surgical Oncology at the Massachusetts General Hospital/Brigham and Women's Hospital.

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