Safer Care Victoria’s Best Care resources support patients and healthcare providers to have conversations and make decisions together about the most appropriate pathways for care.
This resource, developed for clinicians, details a specific elective surgery procedure that should now only be done for specific indications. Evidence-based recommendations that detail ‘best care’ pathways should be discussed with your patient to determine the most appropriate pathway of care.
Advice
A double mastectomy should not routinely be performed on patients who have a single breast with cancer and where there is no genetic predisposition to cancer (for example, identified BRCA1 or BRCA2 gene mutation).
When is the procedure indicated?
In cases of hereditary breast cancer, mutations in human genes (for example, the BRCA1 and BRCA2 genes) have been found to significantly increase the risk of developing breast cancer.
A double mastectomy may be considered for those with a high genetic risk of developing a second breast cancer (such as those with identified BRCA1 or BRCA2 mutations) to reduce their risk of developing further breast cancer.
Removing the contralateral breast may be indicated in the case of reconstruction, symmetrisation or fully informed patient choice, and all decisions to undertake a double mastectomy should be made via a multidisciplinary team approach.
Best care recommendations
Those who have a single breast with cancer and where there is no genetic predisposition to cancer should be advised against having a double mastectomy.
A double mastectomy should not be routinely performed on these patients until they have been provided with adequate, understandable information about the minimal effect the procedure has on improving life expectancy and the low risk of developing cancer in the other breast.
Recommended surgical options for treating average-risk patients include breast-conserving surgery (such as a lumpectomy) and single mastectomy of the breast with cancer, as well as other options determined by the cancer type and severity.
Evidence
Choosing Wisely Canada. General surgery – seven things physicians and patients should question. Canada: Choosing Wisely Canada; 2019 [updated 2019 Oct; cited 2020 Jun 24].
Choosing Wisely. American Society of Breast Surgeons – Mastectomies for single breast cancer patients. Philadelphia (PN): Choosing Wisely; 2016 [updated 2016 Jun 27; cited 2020 Jun 24].
Fayanju OM, Stoll CR, Fowler S, Colditz GA, Margenthaler JA. Contralateral prophylactic mastectomy after unilateral breast cancer: a systematic review and meta-analysis. Annals of Surgery [Internet]. 2014 Dec [cited 2020 Jun 24]; 260(6): 1000-10.
Kenny R, Reed M, Subramanian A. Mastectomy for risk reduction or symmetry in women without high risk gene mutation: A review. International Journal of Surgery [Internet] 2018 Feb [cited 2020 Aug 12]; 50:60-4.
Metcalfe K, Gershman S, Ghadirian P, Lynch HT, Snyder C, Tung N, et al. Contralateral mastectomy and survival after breast cancer in carriers of BRCA1 and BRCA2 mutations: retrospective analysis. BMJ [Internet]. 2014 [cited 2020 Jun 23];348:226.
Momoh AO, Cohen WA, Kidwell KM, Hamill JB, Qi J, Pusic AL, et al. Tradeoffs associated with contralateral prophylactic mastectomy in women choosing breast reconstruction: results of a prospective multicenter cohort. Annals of Surgery [Internet]. 2017 [cited 2020 Jun 23]; 266(1):158-64.
National Cancer Institute. BRCA mutations: cancer risk and genetic testing. USA: National Cancer Institute; 2018 [updated 2018 Jan 30; cited 2020 Jun 23].
Wright FC, Look Hong NJ, Quan ML, Beyfuss K, Temple S, Covelli A, et al. Indications for contralateral prophylactic mastectomy: a consensus statement using modified Delphi methodology. Annals of Surgery [Internet]. 2018 Feb [cited 2020 Jun 24]; 267(2):271-9.