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    VICC Sees Spike in Bilateral Mastectomies

    October 1, 2008

    Ingrid Meszoely, M.D.From 2003 through 2007 Vanderbilt-Ingram Cancer Center recorded a fivefold increase in the number of women choosing to undergo a bilateral mastectomy following a diagnosis of breast cancer in one breast. More than one-third of those patients had no known risk factors for cancer in the second breast, other than their current cancer diagnosis.

    This data indicates that Hollywood actress Christina Applegate isn’t alone in choosing to undergo a bilateral mastectomy following a diagnosis of breast cancer in one breast. Applegate has said her decision was influenced by her increased risk of developing a second breast cancer due to an inherited mutated gene (BRCA1). In the United States, only 5 percent to 10 percent of breast cancers are due to a hereditary mutation, whereas 80 percent have no known identifiable cause.

    “The increase at Vanderbilt-Ingram parallels the findings in a study from a group at the University of Minnesota published last year in the Journal of Clinical Oncology.  Dr. Todd Tuttle and his group noted a two and a half-fold nationwide increase in mastectomies for the unaffected side,” said Ingrid Meszoely, M.D., assistant professor of Surgery and clinical director of the Vanderbilt Breast Center. “The rationale for choosing this option is unclear in most women.”

    In 2003, Vanderbilt-Ingram surgeons performed five bilateral mastectomies (1.7 percent): one patient had cancer in both breasts; one had a BRCA gene mutation that dramatically increases the risk of breast cancer; two had strong family histories of breast cancer and one had no known risk factors. By 2007, the number of bilateral mastectomies jumped to 26 (10 percent): one patient had cancer in both breasts; 15 had a family history of breast cancer; two had mammograms that were difficult to follow and assure the absence of a malignancy and the remaining eight patients (32 percent) had no other risk factors.

    “While the incidence of bilateral cancers is less than 3 percent, we are seeing an increase in the number of women choosing to have the second breast removed as a precautionary measure,” Meszoely said. “Unfortunately bilateral mastectomies do not provide 100 percent protection from breast cancer due to the inability to remove all breast tissue from the chest wall.”

    “For most women, the risk of developing a cancer in the unaffected breast is only .5 to .75 percent per year and is not cumulative, whereas the risk of local recurrence (in the mastectomy scar of the affected breast) is approximately 5 to 10 percent. The risk of systemic recurrence (somewhere in the body beyond the breast) is higher in many women than the risk of a new primary cancer in the second breast and this is what influences survival. It is therefore unlikely that many of these patients will achieve a survival benefit from bilateral mastectomies.”

    The Vanderbilt Breast Center operates a High Risk Clinic where health care professionals counsel and manage care for individuals at high risk (like Christina Applegate) due to either hereditary mutations or strong family history of breast cancer.

    The Society of Surgical Oncology lists these indications for a prophylactic mastectomy: BRCA mutation carriers, strong family history of breast cancer among first degree relatives, histological risk factors such as atypical hyperplasia or lobular carcinoma in situ (LCIS), difficult surveillance with mammogram or MRI due to dense breasts or microcalcifications in the unaffected breast, or patients who will have difficulty achieving symmetry with reconstruction.