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The information on this page was reviewed and approved by
Maurie Markman, MD, President, Medicine & Science at CTCA.

This page was updated on April 2, 2021.

Preventative mastectomy

If you have a very strong family history of breast cancer, you may consider having your breasts removed to reduce the chance of developing breast cancer. This surgery is known as prophylactic mastectomy.

Before making this important and difficult decision, there are a few factors to consider.

What makes someone very high risk for breast cancer?

Factors that put a person in the very high risk category are:

Having an inherited mutation in the BRCA1 or BRCA2 genes, which help make proteins that repair damaged DNA. You also are more likely to develop breast cancer if you have a high penetration of one of several other genes associated with greater risk of breast cancer, including ATM, TP53, CDH1 or PTEN. When these genes mutate, it can cause cells to grow abnormally, and cancer is the uncontrolled growth of abnormal cells. About 5 to 10 percent of breast cancers are believed to have hereditary causes, according to the U.S. Centers for Disease Control and Prevention (CDC). (Genetic testing can tell you whether you have these mutations.)

Having had radiation therapy to your chest before you turned 30. You may have had radiation to your chest as a child to treat a different cancer, such as Hodgkin lymphoma or non-Hodgkin lymphoma. The radiation increases your chances of breast cancer as you get older.

Having multiple family members who had or have breast or ovarian cancer, or at least one close relative who was diagnosed with breast cancer at a young age. Close relatives include your sister, mother or daughter. Close relatives also include a male diagnosed with breast cancer.

Having a history of having breast cancer yourself, in addition to other risk factors. You’re at greater risk of developing breast cancer in your second or contralateral breast if you also have a strong family history of breast cancer.

Having been found to have lobular carcinoma in situ (LCIS). LCIS isn’t cancer, but a condition where abnormal cells are found in small lobes in your breast. LCIS increases your risk of developing breast cancer in either one of your breasts. However, most breast surgeons will tell you that LCIS alone isn’t a reason to consider prophylactic mastectomy. You should have other risk factors as well.

What are your surgical options?

Bilateral prophylactic mastectomy

A bilateral prophylactic mastectomy or bilateral risk-reducing mastectomy, removing both breasts, is the most common risk-reducing surgery performed. Options include:

Subcutaneous or nipple-sparing mastectomy: During this procedure, the surgeon may remove as much breast tissue as possible while leaving your nipples intact. The advantage to the nipple-sparing mastectomy is that if you choose to have breast reconstruction surgery, it’ll look more natural. This option is best for women with small to medium-sized breasts.

Skin-sparing mastectomy: During this procedure, the surgeon removes only the skin of the nipple, areola and the scar from your original biopsy. Then, the surgeon removes the breast tissue through a small opening that has been created. This leaves the skin needed for immediate reconstruction and a pouch to accommodate an implant or reconstruction with your own tissue.

Total mastectomy: If you choose this procedure, the surgeon will remove both breasts, including your nipples. The advantage to a total mastectomy is that it removes more breast tissue than a nipple-sparing or skin-sparing mastectomy; with little to no breast tissue, the chances are greater that you will not develop breast cancer. However, even this procedure isn’t 100 percent. The reason is that not all the breast tissue that could become cancerous can be removed. Your chest wall may contain breast tissue, and it is not usually removed during a mastectomy. Breast tissue also may be in your armpits, near your collarbone and down toward your abdomen.

How effective are these surgeries?

Bilateral prophylactic mastectomy can reduce the risk of breast cancer by at least 95 percent if you have a disease-causing mutation in your BRCA1 or BRCA2 gene, according to the National Cancer Institute. It can reduce your risk of developing breast cancer by up to 90 percent if you have a strong family history of breast cancer.

Will your health insurance cover the surgery?

Most health insurance companies have official policies on prophylactic surgery. It must be shown to be medically necessary. However, the criteria they use to determine what is and isn’t medically necessary can vary. Your insurance company is likely to ask for a second opinion or for your provider to write a letter stating why it’s medically necessary for you to undergo this procedure. A law enacted in 1999, the Women’s Health and Cancer Rights Act, requires most health insurers to cover breast reconstruction surgery after a mastectomy.

What are your other options?

Prophylactic mastectomy isn’t your only option to reduce the risk of developing breast  cancer. Here’s what else you should talk to your doctor about:

Enhanced screening

Women at high risk of breast cancer should undergo more frequent breast cancer screening, also called enhanced screening.

  • The American Cancer Society recommends women at high risk begin screening at age 30 or at the age their doctor recommends for them based on their medical and family history.
  • It’s recommended that you stagger your MRI and mammogram—one every six months—to increase the chances of catching any cancer in its early stages.
  • If you carry mutations in some genes that increase your risk of breast cancer, undergoing imaging with radiation may increase the likelihood of developing breast cancer. Talk to your doctor about the different screening options and which are best for you.

Chemoprevention

The FDA has approved two drugs, tamoxifen and raloxifene, that may be taken proactively to reduce the risk of developing breast cancer. Both drugs block estrogen in breast cells.

Studies are ongoing to determine how much these drugs help lower breast cancer risk. Some studies have shown they may lower the risk by about 40 percent, according to the American Cancer Society.

They can have side effects, including:

  • Menopausal symptoms
  • Blood clots
  • Cancers of the uterus

Other drugs

Aromatase inhibitors such as anastrozole (Arimidex®) and exemestane (Aromasin®) lower estrogen and therefore may lower your breast cancer risk. However, they haven’t yet been approved by the FDA to lower breast cancer risk.

Aromatase inhibitors can have side effects, including:

  • Symptoms of menopause, such as hot flashes and night sweats
  • Muscle and joint pain
  • Bone-thinning, leading to brittle bones and osteoporosis
  • High cholesterol

Healthy lifestyle

Some everyday factors that have been shown to reduce the risk of breast cancer. These include:

  • Maintaining a healthy weight
  • Getting regular exercise
  • Limiting alcohol use
  • Avoiding hormone therapy during menopause

Removing your ovaries (salpingo-oophorectomy)

This surgery is sometimes called prophylactic oophorectomy. It involves removing your ovaries and fallopian tubes. It’s done in women who are premenopausal and at very high risk of developing breast cancer because ovaries produce the hormone estrogen, which can cause some breast cancers to grow. If you remove the ovaries, you reduce the amount of estrogen in your body, which may slow the growth of breast cancer. 

This procedure will put you into medically-induced menopause. Menopause can cause symptoms of its own, including hot flashes, insomnia, anxiety, depression and lack of bladder control. Surgical menopause may also cause decreased sex drive and vaginal dryness.

Salpingo-oophorectomy has been shown to reduce the risk of ovarian cancer by about 90 percent and of breast cancer by about 50 percent in women who are at very high risk of developing these cancers, according to the American Society of Clinical Oncology.

Some women opt to have their ovaries removed as well as their breasts. If you choose to have both removed, you may want to discuss menopausal hormone therapy with your doctor. While some hormone therapy promotes breast cancer, you’ve greatly reduced your risk with your bilateral prophylactic mastectomy and salpingo-oophorectomy.

Who can help you decide what to do?

This is an important decision and something you may want to discuss with your doctor and loved ones. You may also want to consult:

  • A breast reconstruction surgeon
  • A medical social worker or cancer clinical psychologist or psychiatrist to discuss the emotional impact of your decision
  • A genetic counselor to help arrange the necessary testing and review and explain your results 
  • A support group of other women who have considered or undergone these surgeries. The American Cancer Society has a searchable database of support groups.