Key Points Preventive mastectomy (also called prophylactic or risk-reducing mastectomy) is the surgical removal of one or both breasts. It is done to prevent or reduce the risk of breast cancer in women who are at high risk of developing the disease (see Questions 1 and 2). Existing data suggest that preventive mastectomy may significantly reduce (by about 90 percent) the chance of developing breast cancer in moderate- and high-risk women (see Question 3). It is important for a woman who is considering preventive mastectomy to talk with a doctor about her risk of developing breast cancer, the surgical procedure and its potential complications, and alternatives to surgery (see Questions 2, 4, and 5). Many women who choose to have preventive mastectomy also decide to have breast reconstruction to restore the shape of the breast (see Question 6).

1. What is preventive mastectomy, and what types of procedures are used in preventive mastectomy?

Preventive mastectomy (also called prophylactic or risk-reducing mastectomy ) is the surgical removal of one or both breasts in an effort to prevent or reduce the risk of breast cancer (1). Preventive mastectomy involves one of two basic procedures: total mastectomy and subcutaneous mastectomy. In a total mastectomy, the doctor removes the entire breast and nipple. In a subcutaneous mastectomy, the doctor removes the breast tissue but leaves the nipple intact. Doctors most often recommend a total mastectomy because it removes more tissue than a subcutaneous mastectomy. A total mastectomy provides the greatest protection against cancer developing in any remaining breast tissue.

2. Why would a woman consider undergoing preventive mastectomy?

Women who are at high risk of developing breast cancer may consider preventive mastectomy as a way of decreasing their risk of this disease. Some of the factors that increase a woman's chance of developing breast cancer include the following (2, 3, 4, 5, 6):

• Previous breast cancer— A woman who has had cancer in one breast is more likely to develop a new cancer in the opposite breast. Occasionally, such women may consider preventive mastectomy to decrease the chance of developing a new breast cancer.

• Family history of breast cancer— Preventive mastectomy may be an option for a woman whose mother, sister, or daughter had breast cancer, especially if they were diagnosed before age 50. If multiple family members have breast or ovarian cancer, then a woman's risk of breast cancer may be even higher.

• Breast cancer-causing gene alteration— A woman who tests positive for changes, or mutations, in certain genes that increase the risk of breast cancer (such as the BRCA1 or BRCA2 gene) may consider preventive mastectomy.

• Lobular carcinoma in situ— Preventive mastectomy is sometimes considered for a woman with lobular carcinoma in situ, a condition that increases the risk of developing breast cancer in either breast.

• Diffuse and indeterminate breast microcalcifications or dense breasts— Rarely, preventive mastectomy may be considered for a woman who has diffuse and indeterminate breast microcalcifications (tiny deposits of calcium in the breast) or for a woman whose breast tissue is very dense. Dense breast tissue is linked to an increased risk of breast cancer and also makes diagnosing breast abnormalities difficult. Multiple biopsies, which may be necessary for diagnosing abnormalities in dense breasts, cause scarring and further complicate examination of the breast tissue, by both physical examination and mammography.
• Radiation therapy— A woman who had radiation therapy to the chest (including the breasts) before age 30 is at an increased risk of developing breast cancer throughout her life. This includes women treated for Hodgkin lymphoma.

It is important for a woman who is considering preventive mastectomy to talk with a doctor about her risk of developing breast cancer (with or without a mastectomy), the surgical procedure, and potential complications. All women are different, so preventive mastectomy should be considered in the context of each woman's unique risk factors and her level of concern.

3. How effective is preventive mastectomy in preventing or reducing the risk of breast cancer?

Existing data suggest that preventive mastectomy may significantly reduce (by about 90 percent) the chance of developing breast cancer in moderate- and high-risk women (2, 6, 7). However, no one can be certain that this procedure will protect an individual woman from breast cancer. Breast tissue is widely distributed on the chest wall, and can sometimes be found in the armpit, above the collarbone, and as far down as the abdomen. Because it is impossible for a surgeon to remove all breast tissue, breast cancer can still develop in the small amount of remaining tissue

4. What are the possible drawbacks of preventive mastectomy?

Like any other surgery, complications such as bleeding or infection can occur (1). Preventive mastectomy is irreversible and can have psychological effects on a woman due to a change in body image and loss of normal breast functions (3, 4, 5, 7, 8, 9). A woman should discuss her feelings about mastectomy, as well as alternatives to surgery, with her health care providers. Some women obtain a second medical opinion to help with the decision.

5. What alternatives to surgery exist for preventing or reducing the risk of breast cancer?

Doctors do not always agree on the most effective way to manage the care of women who have a strong family history of breast cancer and/or have other risk factors for the disease. Some doctors may advise very close monitoring (periodic mammograms, regular checkups that include a clinical breast examination performed by a health care professional, and monthly breast self-examinations) to increase the chance of detecting breast cancer at an early stage (2, 4). Some doctors may recommend preventive mastectomy, while others may prescribe tamoxifen or raloxifene, medications that have been shown to decrease the chances of getting breast cancer in women at high risk of the disease (2, 4, 8, 10, 11). (More information about tamoxifen and raloxifene is available in the National Cancer Institute's (NCI) fact sheets, Tamoxifen: Questions and Answers, which can be found at http://www.cancer.gov/cancertopics/factsheet/Therapy/tamoxifen on the Internet, and The Study of Tamoxifen and Raloxifene (STAR): Questions and Answers, which can be found at http://www.cancer.gov/cancertopics/factsheet/STARresultsQandA on the Internet.)

Doctors may also encourage women at high risk to limit their consumption of alcohol, eat a low-fat diet, engage in regular exercise, and avoid menopausal hormone use (8). Although these lifestyle recommendations make sense and are part of an overall healthy way of living, we do not yet have clear and convincing proof that they specifically reduce the risk of developing breast cancer.

6. What is breast reconstruction?

Breast reconstruction is a plastic surgery procedure in which the shape of the breast is rebuilt. Many women who choose to have preventive mastectomy also decide to have breast reconstruction, either at the time of the mastectomy or at some later time.

Before performing breast reconstruction, the plastic surgeon carefully examines the breasts and discusses the reconstruction options. In one type of reconstructive procedure, the surgeon inserts an implant (a balloon-like device filled with saline or silicone) under the skin and the chest muscles. Another procedure, called tissue flap reconstruction, uses skin, fat, and muscle from the woman's abdomen, back, or buttocks to create the breast shape. The surgeon will discuss with the patient any limitations on exercise or arm motion that might result from these operations.

7. What type of follow-up care is needed after reconstructive surgery?

Women who have reconstructive surgery are monitored carefully to detect and treat complications, such as infection, movement of the implant, or contracture (the formation of a firm, fibrous shell or scar tissue around the implant caused by the body's reaction to the implant). Women who have tissue flap reconstruction may want to ask their surgeon about physical therapy, which can help them adjust to limitations in activity and exercise after surgery (12). Routine screening for breast cancer is also part of the postoperative follow-up, because the risk of cancer cannot be completely eliminated. When women with breast implants have mammograms, they should tell the radiology technician about the implant. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant. However, women who have had reconstructive surgery on both breasts should ask their doctors whether mammograms are still necessary. (More information about mammograms can be found in the NCI fact sheet, Screening Mammograms: Questions and Answers, at http://www.cancer.gov/cancertopics/factsheet/Detection/screening-mammograms on the Internet.)

8. Where can a person find more information about breast implants?

The U.S. Food and Drug Administration (FDA) regulates the use of breast implants and can supply detailed information about these devices. To listen to recorded information or request free printed material on breast implants, consumers can contact the FDA Center for Devices and Radiological Health (CDRH) at:

Address:	Consumer Staff CDRH/FDA HFZ-210 1350 Piccard Drive Rockville, MD 20850
Telephone:	1–800–638–2041, toll-free 240–276–3103 (Call between 8:00 a.m. and 4:30 p.m., Eastern Time, for either number.)
E-mail:	dsmica@cdrh.fda.gov
Web site:	http://www.fda.gov/cdrh/consumer/index.html http://www.fda.gov/cdrh/breastimplants (Breast Implants Home Page)

Selected References

1. Singletary SE. Techniques in surgery: Therapeutic and prophylactic mastectomy. In: Harris JR, Lippman ME, Morrow M, Osborn CK, editors. Diseases of the Breast. 3^rd ed. Philadelphia: Lippincott Williams and Wilkins, 2004.
2. Sherry RM. Cancer prevention: Role of surgery in cancer prevention. In: DeVita VT Jr., Hellman S, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology. Vol. 1 and 2. 6^th ed. Philadelphia: Lippincott Williams and Wilkins, 2001.
3. Dickson RB, Lippman ME. Cancer of the breast. In: DeVita VT Jr., Hellman S, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology. Vol. 1 and 2. 6^th ed. Philadelphia: Lippincott Williams and Wilkins, 2001.
4. Sakorafas GH. Women at high risk for breast cancer: Preventive strategies. The Mount Sinai Journal of Medicine 2002; 69(4):264–266.
5. Taucher S, Gnant M, Jakesz R. Preventive mastectomy in patients at breast cancer risk due to genetic alterations in the BRCA1 and BRCA2 gene. Langenbeck's Archives of Surgery 2003; 388(1):3–8.
6. Anderson BO. Prophylactic surgery to reduce breast cancer risk: A brief literature review. The Breast Journal 2001; 7(5):321–330.
7. Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. The New England Journal of Medicine 1999; 340(2):77–84.
8. Keefe KA, Meyskens FL Jr. Cancer prevention. In: Abeloff MD, Armitage JO, Lichter AS, Niederhuber JE, editors. Clinical Oncology. 2^nd ed. London: Churchill Livingstone, 2000.
9. Levine DA, Gemignani ML. Prophylactic surgery in hereditary breast/ovarian cancer syndrome. Oncology 2003; 17(7):932–941.
10. Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for the prevention of breast cancer: Current status of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. Journal of the National Cancer Institute 2005; 97(22):1652–1662.
11. Vogel VG, Costantino JP, Wickerham DL, et al. Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes: The NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 Trial. Journal of the American Medical Association 2006; 295(23):2727–2741.
12. Monteiro M. Physical therapy implications following the TRAM procedure. Physical Therapy 1997; 77(7):765–770.

# # #

• National Cancer Institute Fact Sheet 3.62, Genetic Testing for BRCA1 and BRCA2: It's Your Choice ¹
  (http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA)
• National Cancer Institute Fact Sheet 5.6, Probability of Breast Cancer in American Women ²
  (http://www.cancer.gov/cancertopics/factsheet/Detection/probability-breast-cancer)
• National Cancer Institute Fact Sheet 5.14, Improving Methods for Breast Cancer Detection and Diagnosis ³
  (http://www.cancer.gov/cancertopics/factsheet/Detection/breast-cancer)
• National Cancer Institute Fact Sheet 5.28, Screening Mammograms: Questions and Answers ⁴
  (http://www.cancer.gov/cancertopics/factsheet/Detection/screening-mammograms)
• National Cancer Institute Fact Sheet 7.16, Tamoxifen: Questions and Answers ⁵
  (http://www.cancer.gov/cancertopics/factsheet/Therapy/tamoxifen)
• National Cancer Institute Fact Sheet 7.47, How To Find a Doctor or Treatment Facility If You Have Cancer ⁶
  (http://www.cancer.gov/cancertopics/factsheet/Therapy/doctor-facility)
• What You Need To Know About™ Breast Cancer ⁷
  (http://www.cancer.gov/cancertopics/wyntk/breast)

For more help, contact:

NCI's Cancer Information Service
Telephone (toll-free): 1–800–4–CANCER (1–800–422–6237)
TTY (toll-free): 1–800–332–8615
LiveHelp^® online chat: https://cissecure.nci.nih.gov/livehelp/welcome.asp

Glossary Terms

The area of the body that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.

Not normal. An abnormal lesion or growth may be cancer, premalignant (likely to become cancer), or benign (not cancer).

A change resulting in something that is different from the original.

The removal of cells or tissues for examination by a pathologist. The pathologist may study the tissue under a microscope or perform other tests on the cells or tissue. There are many different types of biopsy procedures. The most common types include: (1) incisional biopsy, in which only a sample of tissue is removed; (2) excisional biopsy, in which an entire lump or suspicious area is removed; and (3) needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.

A gene on chromosome 17 that normally helps to suppress cell growth. A person who inherits certain mutations (changes) in a BRCA1 gene has a higher risk of getting breast, ovarian, prostate, and other types of cancer.

A gene on chromosome 13 that normally helps to suppress cell growth. A person who inherits certain mutations (changes) in a BRCA2 gene has a higher risk of getting breast, ovarian, prostate, and other types of cancer.

Glandular organ located on the chest. The breast is made up of connective tissue, fat, and breast tissue that contains the glands that can make milk. Also called mammary gland.

Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare.

A silicone gel-filled or saline-filled sac placed under the chest muscle to restore breast shape.

Surgery to rebuild the shape of the breast after a mastectomy.

A mineral needed for healthy teeth, bones, and other body tissues. It is the most common mineral in the body. A deposit of calcium in body tissues, such as breast tissue, may be a sign of disease.

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

The muscles, bones, and joints that make up the area of the body between the neck and the abdomen.

A physical exam of the breast performed by a health care provider to check for lumps or other changes. Also called CBE.

The process of identifying a disease, such as cancer, from its signs and symptoms.

The things a person eats and drinks.

Widely spread; not localized or confined.

A record of a person's current and past illnesses, and those of his or her parents, brothers, sisters, children, and other family members. A family history shows the pattern of certain diseases in a family, and helps to determine risk factors for those and other diseases. Also called family medical history.

Containing or resembling fibers.

Monitoring a person's health over time after treatment. This includes keeping track of the health of people who participate in a clinical study or clinical trial for a period of time, both during the study and after the study ends.

The functional and physical unit of heredity passed from parent to offspring. Genes are pieces of DNA, and most genes contain the information for making a specific protein.

One of many chemicals made by glands in the body. Hormones circulate in the bloodstream and control the actions of certain cells or organs. Some hormones can also be made in the laboratory.

A substance or object that is put in the body as a prosthesis, or for treatment or diagnosis.

Invasion and multiplication of germs in the body. Infections can occur in any part of the body and can spread throughout the body. The germs may be bacteria, viruses, yeast, or fungi. They can cause a fever and other problems, depending on where the infection occurs. When the body’s natural defense system is strong, it can often fight the germs and prevent infection. Some cancer treatments can weaken the natural defense system.

A condition in which abnormal cells are found in the lobules of the breast. Lobular carcinoma in situ seldom becomes invasive cancer; however, having it in one breast increases the risk of developing breast cancer in either breast. Also called LCIS.

Cancer that begins in cells of the immune system. There are two basic categories of lymphomas. One kind is Hodgkin lymphoma, which is marked by the presence of a type of cell called the Reed-Sternberg cell. The other category is non-Hodgkin lymphomas, which includes a large, diverse group of cancers of immune system cells. Non-Hodgkin lymphomas can be further divided into cancers that have an indolent (slow-growing) course and those that have an aggressive (fast-growing) course. These subtypes behave and respond to treatment differently. Both Hodgkin and non-Hodgkin lymphomas can occur in children and adults, and prognosis and treatment depend on the stage and the type of cancer.

An x-ray of the breast.

The use of x-rays to create a picture of the breast.

Surgery to remove the breast (or as much of the breast tissue as possible).

The time of life when a woman’s ovaries stop working and menstrual periods stop. Natural menopause usually occurs around age 50. A woman is said to be in menopause when she hasn’t had a period for 12 months in a row. Symptoms of menopause include hot flashes, mood swings, night sweats, vaginal dryness, trouble concentrating, and infertility.

Any change in the DNA of a cell. Mutations may be caused by mistakes during cell division, or they may be caused by exposure to DNA-damaging agents in the environment. Mutations can be harmful, beneficial, or have no effect. If they occur in cells that make eggs or sperm, they can be inherited; if mutations occur in other types of cells, they are not inherited. Certain mutations may lead to cancer or other diseases.

The National Cancer Institute, part of the National Institutes of Health of the United States Department of Health and Human Services, is the Federal Government's principal agency for cancer research. The National Cancer Institute conducts, coordinates, and funds cancer research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer. Access the National Cancer Institute Web site at http://www.cancer.gov. Also called NCI.

In anatomy, the small raised area in the center of the breast through which milk can flow to the outside.

Cancer that forms in tissues of the ovary (one of a pair of female reproductive glands in which the ova, or eggs, are formed). Most ovarian cancers are either ovarian epithelial carcinomas (cancer that begins in the cells on the surface of the ovary) or malignant germ cell tumors (cancer that begins in egg cells).

An exam of the body to check for general signs of disease.

The use of exercises and physical activities to help condition muscles and restore strength and movement. For example, physical therapy can be used to restore arm and shoulder movement and build back strength after breast cancer surgery.

A surgeon who specializes in reducing scarring or disfigurement that may occur as a result of accidents, birth defects, or treatment for diseases.

An operation that restores or improves the appearance of body structures.

After surgery.

Surgery to reduce the risk of developing breast cancer by removing one or both breasts before disease develops. Also called prophylactic mastectomy.

In medicine, something that prevents or protects.

The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called irradiation and radiotherapy.

The use of radiation (such as x-rays) or other imaging technologies (such as ultrasound and magnetic resonance imaging) to diagnose or treat disease.

The active ingredient in a drug used to reduce the risk of invasive breast cancer in postmenopausal women who are at high risk of the disease or who have osteoporosis. It is also used to prevent and treat osteoporosis in postmenopausal women. It is also being studied in the prevention of breast cancer in certain premenopausal women and in the prevention and treatment of other conditions. Raloxifene blocks the effects of the hormone estrogen in the breast and increases the amount of calcium in bone. It is a type of selective estrogen receptor modulator (SERM).

Surgery that is done to reshape or rebuild (reconstruct) a part of the body changed by previous surgery.

Something that may increase the chance of developing a disease. Some examples of risk factors for cancer include age, a family history of certain cancers, use of tobacco products, certain eating habits, obesity, lack of exercise, exposure to radiation or other cancer-causing agents, and certain genetic changes.

A solution of salt and water.

Checking for disease when there are no symptoms. Since screening may find diseases at an early stage, there may be a better chance of curing the disease. Examples of cancer screening tests are the mammogram (breast), colonoscopy (colon), Pap smear (cervix), and PSA blood level and digital rectal exam (prostate). Screening can also include checking for a person’s risk of developing an inherited disease by doing a genetic test.

A synthetic gel that is used as an outer coating on breast implants and as the inside filling of some implants.

The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.

Beneath the skin.

A doctor who removes or repairs a part of the body by operating on the patient.

A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.

A drug used to treat certain types of breast cancer in women and men. It is also used to prevent breast cancer in women who have had ductal carcinoma in situ (abnormal cells in the ducts of the breast) and in women who are at a high risk of developing breast cancer. Tamoxifen is also being studied in the treatment of other types of cancer. It blocks the effects of the hormone estrogen in the breast. Tamoxifen is a type of antiestrogen. Also called tamoxifen citrate.

A group or layer of cells that work together to perform a specific function.

A type of breast reconstruction in which a flap of tissue is surgically moved from another area of the body to the chest, and formed into a new breast mound.

Removal of the breast. Also called simple mastectomy.