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Healthy You

Risk Reducing Breast Surgery: Is It for You?

January 27, 2009 8:00 PM with Dr. David Winchester

David J. Winchester, MD, Professor of Surgery and Oncology Surgeon, discusses surgical options for women who are at increased risk for breast cancer.

Grant Gannon (Moderator) - 7:51 PM:
Good evening and welcome to tonight's chat, "Risk Reducing Breast Surgery: Is it for you?" With us tonight is Dr. David Winchester. The chat will begin in just a few minutes. You can start submitting your questions using the form you see below.

  Karen (Long Grove, IL) - 8:04 PM:
I’m 50 & have tested negative for BRCA1 & BRCA2. I have some family history of breast cancer. I’m trying to determine whether my family history puts me at higher risk for a contra lateral breast cancer. Which family relationships & # of impacted family members (maternal/paternal) are considered in determining whether there is an increased family history risk? When do you recommend risk reducing breast surgery? Can you speak to whether any data from Dr. Narod’s study has been published? Thanks
Dr. David Winchester (NorthShore)
Good evening. Thank you for your question. The most important family members are your first degree relatives (siblings and parents) but sometimes that represents a limited sampling if you have a small family or if one or more of your parents are deceased. The medical history of more distant relatives may provide additional insight to explain a potential genetic explanation based upon a young age at diagnosis. Taking into account this history, even if one has tested negative for BRCA, may define an increased risk of developing breast cancer and may lead to consideration of risk-reducing strategies. Dr. Narod from Toronto noted a 5-fold increase risk of developing breast cancer with a strong family history with negative gene test results. To my knowledge, this data remains unpublished but was reported in abstract form at a recent meeting. Balancing this risk with the patient's anxiety of screening helps to define which patients should consider surgery.

  Tara (NY) - 8:12 PM:
Is there a suggested age to have this surgery done?
Dr. David Winchester (NorthShore)
Once a patient's risk has been defined by an assessment which may or may not include gene testing, the decision to proceed with surgery depends upon a number of factors including the annualized risk of developing breast cancer, the desire to breast feed, family planning, work demands, or other life events, and the desire to take steps to reduce risk. BRCA carriers or other high risk patients need to be followed closely during their decision making with physical examinations, mammograms, and MRIs until if and when they wish to intervene. Most clinicians recommend intervening when the patient is comfortable in doing so, preferably before age 35-40.

  Lilian (Chicago, Illinois) - 8:18 PM:
I'm a long time survivor of breast cancer and have already had a mastectomy. Would I still be a candidate to have the surgery?
Dr. David Winchester (NorthShore)
If your risk of developing a second cancer (in your other breast) is high enough, you would be a candidate to have a risk-reducing mastectomy for your remaining breast.

  Mary (Niles, IL) - 8:19 PM:
If you had risk reducing breast surgery what are the possible side effects of the surgery itself long term?
Dr. David Winchester (NorthShore)
The risks are primary short term and are related to the surgical recovery. These include wound infections, tissue ischemia, and bleeding. These are infrequent complications, occurring in less than 2-3% of patients undergoing surgery. Long term risks would include cosmetic issues related to the reconstruction, the risk of developing breast cancer (less than 5-10%), and pain from the procedure (usually very limited and short term).

  Brenda (Chicago, IL) - 8:22 PM:
I'm BRCA1+ and considering prophylactic surgery. There are a few things about it giving me pause... loss of sensation at the top of the list. But I'm also concerned about complications, like infection, that may lead to months of reconstruction issues and possibly implant failure (I'm not a candidate for flap recon). What would you say is the current rate of complications for prophy mastectomy/immediate recon with implants? Is it any higher or lower with the immediate implant vs. expander method?
Dr. David Winchester (NorthShore)
Loss of sensation is one concern but diminishes over time. One option that may offer less sensory issues is a nipple sparing mastectomy. This is a procedure that we have been performing at NorthShore for the past few years with excellent results. This places the incision in a more peripheral location and is much smaller than most mastectomy incisions. Over time, most patients note a significant recovery of their sensation. Infection issues requiring the removal of an implant occur less than one percent of cases. The risk of infection is equally low for either a tissue expander or immediate implant. This risk is 2-3% but most are treated successfully without requiring the removal of the implant if that is the form of reconstruction selected.

  Julie (Grayslake) - 8:28 PM:
I am 52 and just found out that I am positive for the BRCA2 mutation-my sister who is 42 was diagnosed with breast ca last year and just found out that she too has the BRCA2 mutation- there is so much information- how do I decide what is the best option for me to reduce my risk? Thank you
Dr. David Winchester (NorthShore)
Your best option is to gather more detailed information regarding your risk and options of close observation versus risk-reducing strategies. I would start with a consultation with a breast surgeon and if interested, proceed to meet with a plastic surgeon and talk to other patients that have been through the experience.

  Jennifer Boehnel (Evanston, IL) - 8:31 PM:
There are 5 generations of breast cancer on my mother's side (herself included). However, she tested negative for the BRCA gene, as did my sister. My lifetime risk is 33%- does that risk increase as I age? Alternatively, I am now 38. IS my risk now only 10% as compared to a much higher percentage when I am 60?
Dr. David Winchester (NorthShore)
Your risk is more difficult to estimate with a negative gene test result but is elevated. It is hard to define your risk with a number but in general, the risk of breast cancer increases as you age.

  Brenda (Chicago, IL) - 8:36 PM:
Under what circumstances--if any--would you discourage someone from having risk-reducing surgery?
Dr. David Winchester (NorthShore)
I would discourage most patients with a low or average risk to pursue surgery. Older patients have a more limited exposure than younger patients and thus the benefits of surgery would be diminished. Other significant medical history or competing causes of mortality would also be a consideration.

  Margaret (Mt. Prospect, IL) - 8:41 PM:
Hi Dr. Winchester. You did my surgeries this summer & fall. I didn't have a family history of breast cancer, that we could find, but I have 2 daughters and we have been wondering about any increased risks that they may have inherited from me. When should they start getting screened?
Dr. David Winchester (NorthShore)
Hi Margaret, Family members of affected patients should consider screening approximately 10 years before their affected relatives. At the very latest, screening should start at age 40 with annual mammography and physical examination.

  Allison (Wilmette, IL) - 8:45 PM:
I am a 40 year old woman with a family history of five breast cancer cases, three with early onset including my mother and maternal grandmother. My mother has tested negative for a BRCA mutation. I have four very young children and am strongly considering a preventative bilateral mastectomy. What tests/procedures would I need to have done before the surgery? What is my risk factor with a nipple sparing surgery and would I need to continue annual breast exams/testing?
Dr. David Winchester (NorthShore)
With your strong family history and early onset of diagnosis, your situation is a very appropriate one to consider surgery. At age 40, there are very few tests necessary before an operation outside of a complete history and physical examination. Nipple sparing surgery would represent an excellent option and the risks with this approach are similar to a standard mastectomy. Although this is not a new operation, the general interest and support among surgeons has been lower until recently. This is one reason that we offer our patients this operation but encourage them to participate in our clinical trial that helps us to track the outcome of patients who chose this option. The results have been excellent thus far and there are long term data that have demonstrated a 90% reduction in risk with this surgical approach. One of the compelling advantages of choosing surgery to lower risk is that the subsequent screening becomes much simpler and less frequent and does not include xrays.

  Tara (NY) - 8:53 PM:
Can you give me some more information about a growth, referred to as PASH? (I just had a biopsy, revealing that type of growth. I am 23)
Dr. David Winchester (NorthShore)
Pseudoangiomatous hyperplasia is not considered to be a risk factor for developing breast cancer. It usually presents in younger women as a dense nodule and is usually defined by surgical excision.

Grant Gannon (Moderator) - 8:54 PM:
We've got about 10 minutes left in this chat and tonight's topic has been a very popular one! It looks like we won't have time to answer all these excellent questions. For more information please check out these links: Hereditary Breast Cancer -- Surgical Services - Contact Us

  Karen (Long Grove, IL) - 8:54 PM:
If I have mild lymphedema on one side after having a mastectomy with complete lymph node dissection, what impact would a contra lateral risk reduction mastectomy have on my lymphedema on the original mastecomy side?
Dr. David Winchester (NorthShore)
It would not increase your risk of exacerbating lymphedema on your treated side.

Grant Gannon (Moderator) - 8:54 PM:
We have time for one or two more questions.

  Mary (Niles, IL) - 8:58 PM:
How is a patient followed after risk reducing surgery? Do they have MRI's instead of mammograms?
Dr. David Winchester (NorthShore)
After risk-reducing surgery, mammograms and MRIs are no longer necessary. Because the subsequent risk of developing breast cancer is reduced dramatically, an annual physical examination is all that is recommended.

Grant Gannon (Moderator) - 8:59 PM:
Just a reminder, you can view an archive of this chat by visiting

Dr. David Winchester (NorthShore) - 9:01 PM:
Thank you for your participation and interest in this topic. I appreciate your questions and comments. David J Winchester, MD, FACS, Chief of general surgery and surgical oncology, NorthShore Chair of Surgical Oncology, Co-director of the Patricia Nolan Breast Health Center, Professor of Surgery, Northwestern Feinberg School of Medicine. 2650 Ridge Avenue, Walgreens 2507, Evanston, Illinois 60201. 847-570-1700.

This chat has ended.

Thank you very much for your participation.