What About the Other Breast?

For women considering mastectomy of a breast affected by cancer, the question often comes up as to what should be done with the other breast. Across the United States, about 30% of women undergoing mastectomy elect to have prophylactic bilateral or "total" mastectomy. In my practice, this is skewed and about 60% of my patients undergo bilateral prophylactic mastectomy before reconstruction.

There are many arguments that can be made for either having or not having the other breast removed. Some women are so frightened of the cancer that they want the other breast removed so that they never can get breast cancer again. For these women I have argued that some patients who get breast cancer also get ovarian cancer and if they are finished having children, they should also consider having their ovaries removed. If they agree to that, then I ask if they would like any other non-essential body parts removed. Obviously, I have not removed any "extra" body parts, but the point is that each woman needs to make her own decision about the tradeoffs between having additional surgeries and enjoying greater peace of mind. The reasons to keep the other breast include that it is a normal organ and it can provide a certain amount of sexual pleasure.

Bilateral prophylactic mastectomy is often the right choice for a woman who is BRCA gene positive or who has a family history with multiple close relatives who have had breast cancer. Other candidates for prophylactic mastectomy prior to reconstruction include women who have had multiple biopsies of their breasts in the past, women who have difficult-to-read mammograms and are always going back for additional views or studies, and women who are going to require extensive adjustment of the healthy breast to achieve a symmetrical result. While I have reconstructed many patients who have elected to have a prophylactic mastectomy of the healthy breast just out of fear of cancer, I consider this a "soft" reason for a prophylactic mastectomy. Nevertheless, it is the woman's choice to remove the healthy breast and I always respect it.

I have the discussion about bilateral prophylactic mastectomy with every patient because any of the abdominal flaps, including DIEP flap or SIEA flap can be performed only one time.

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