Preventive breast removal

The BRCA 1 and 2 genes are named after the English expression Breast (BR) Cancer (CA). These BRCA genes are anti-cancer genes, so their mutation carries a high risk of developing breast and ovarian cancer. Thus, when a patient is a carrier of a BRCA1 mutation, her risk of developing breast cancer is very high, with an annual risk of about 3% per year, and an estimated risk of between 60 and 70% over the life course.
The mutation of the BRCA gene is detected by an oncogenetic test following an oncogenetic consultation in a patient at high risk of carrying the mutation. These are women who are directly related to a patient who has already been found to have a BRCA mutation, patients already treated for breast or ovarian cancer and in whose families there are many similar cases, or patients with very young breast or ovarian cancer in whom this mutation has been investigated. The transmission of this mutation is autosomal dominant, i.e. it can be transmitted by the father or the mother.
The risk of developing breast and ovarian cancer is very high if you carry a BRCA mutation and these are often cancers that occur in young patients, and whose diagnosis is more difficult because of breast density. For this reason, a prophylactic mastectomy may be considered in the event of a BRCA 1 or 2 mutation. It allows a major reduction in the risk of breast cancer in these transferred patients, from 70% to about 2%.
For patients who have already been treated for breast cancer and in whom a BRCA mutation has been identified, the risk of developing a new breast cancer is about 60%. A surgical procedure can also be proposed, combining a totalizing and prophylactic mastectomy on the already affected side and a prophylactic mastectomy on the other side. In the case of radiotherapy, even if it is old, the risk of complications is higher and reconstruction is considered more difficult and at higher risk of complications. Post-operative follow-up may be more difficult with a higher risk of skin necrosis.
Finally, the risk of developing ovarian cancer is also significant in the context of a BRCA mutation. A bilateral prophylactic adnexectomy (removal of the ovaries and fallopian tubes) is generally proposed after 40 years of age in the case of a BRCA 1 mutation, and after 45 years of age in the case of a BRCA2 mutation.
The goal of a prophylactic mastectomy is to drastically reduce the risk of breast cancer in a patient at high neoplastic risk, especially if she has a mutation of a BRCA gene, while providing immediate quality breast reconstruction that will allow her to return to a normal or almost normal life. This is of course a difficult and delicate ordeal for a woman, often young, and psychological support throughout the process is essential. Moreover, the acceptance of this new breast will depend very much on the patient's request, her expectations, her motivations, but also on the family environment and the quality of the technical and psychological support she will be able to receive.
PRINCIPLES
In mastectomy, prophylactic mastectomy removes the mammary gland and most of the mammary epithelium that may become cancerous. It can be done in different ways:

• in a conventional way by removing a skin spindle and the areolo-nipple plate
• by preserving the skin of the breast
• by keeping the breast skin and the nipple-areolar plate.
  Preserving the nipple-areolar plate (subcutaneous mastectomy or mastectomy preserving the nipple-areolar plate) provides a more satisfactory result for patients who feel less like their breast, and therefore part of their femininity, is being removed. This is often possible in young women, whose breasts are of medium size and have little "falling".
  For patients whose breasts are too large or "fall" too much, the risk of complications by keeping the nipple-areolar plate may be significant, and the surgeon may opt for a classic mastectomy with reconstruction of the nipple-areolar plate (nipple and areola) in a second step.
  In breast reconstruction technique, breast volume can be restored in several ways using a prosthesis or the patient's own tissues (fat, large dorsal flap, DIEP flap, gracilis flap) or, in some cases, techniques combining the patient's tissues with prostheses. An information document on the breast reconstruction technique used will also be provided to you following the consultation. The choice of technique will be made according to the patient's wishes but also according to anatomical and technical constraints.

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Usually, 3 opinions must be collected before the intervention can be considered in practice: the opinion of the onco-geneticist, the opinion of the surgeon, and the opinion of an onco-psychologist. Each intervener provides a part of the information necessary to understand the many issues involved in the intervention.
In addition, a mammary radiological check-up (mammograms, ultrasounds, MRIs) less than 6 months old must be available at the time of the operation (ideally 1.5 months before the operation to allow time to organize if a microbiopsy is necessary). The tests must be normal (ACR1 or ACR2). If a suspicious lesion is discovered or only recently discovered during these examinations, a biopsy would be performed to confirm the nature of this lesion, and consider, if necessary, the search for the sentinel lymph node during mastectomy if necessary.
A regular preoperative check-up is carried out in accordance with the prescriptions.
The anaesthetist will be seen at the latest 48 hours before the operation.
No medication containing aspirin or anti-inflammatory drugs should be taken within 10 days of the procedure.
Type of anesthesia:
it is a classic general anaesthesia.
Hospitalization conditions:
the duration of hospitalization depends on the reconstruction technique used. It varies between 3 and 10 days, excluding intercurrent complications. Depending on the team, the discharge may also be conditioned by the removal of the drainage (in some cases, the patient may leave the facility with a drain that will be removed a few days later).

The duration of the intervention depends on the reconstruction technique used, and varies from 2H30 to 12H, depending on the technique used, the difficulty of the case, the dexterity and the experience of the operator. This will be specified to you by your surgeon.
The mastectomy-reconstruction procedure for high breast risk is considered a difficult procedure with a learning curve and is best performed in a team trained in this type of care.

The carcinological result shows, on large series of patients, a very significant reduction in the risk of developing breast cancer from 70% to 2%. This risk therefore becomes very low but is not zero. In the event of the appearance of a lump on the reconstructed breast remotely from the operation, it is advisable to consult. In all cases, an annual ultrasound scan is recommended in the monitoring of these prophylactic mastectomies.
Regarding the morphological result, prophylactic mastectomy combined with immediate breast reconstruction makes it possible to immediately restore the volume and shape of the breasts, allowing the patient to dress normally with a neckline.
However, the final result is not immediately certain. Whatever the reconstruction technique used, it is necessary to wait two to three months to be able to assess the result of the reconstruction. It is only at this stage that a touch-up or rather a complementary reconstruction can be considered and are part of the therapeutic program and their coverage by the health insurance and by the mutual insurance companies. Concerning this care, the installation of breast implants, and any changes to them, are subject to prior agreement for approval by the health insurance before the operation (to be sent to the medical advisor with acknowledgement of receipt) but are fortunately always accepted in these imperative circumstances.

About Preventive breast removal

The integration of this new breast into the patient's body image can, in some cases, be difficult. The medical and family environment plays an important role in this period when the patient needs to be reassured.
The goal of this surgery is to significantly reduce the risk of breast cancer while providing quality reconstruction, but without being able to claim perfection.
If your wishes are realistic, the result should give you satisfaction (an acceptable breast morphology). However, be careful not to confuse the aesthetic results of cosmetic augmentation surgery by prostheses (in addition to the normal breast) with bilateral breast reconstruction by prostheses (the breast is no longer there to hide any small waves of prostheses).
The use of a qualified plastic surgeon ensures that he or she has the training and competence required to limit the risk of complications, treat them effectively if necessary, and offer you the best possible morphological and aesthetic result.
MEDICAIM organizes your entire stay for you: post-operative nursing care, biological follow-up, therapeutic, nutritional and psychological support.
Any additional questions? Ask your doctor about it: careteam@medicaim.com