Selected Podcast

Preventative Mastectomy

During the last 40 years, researchers have demonstrated that prophylactic mastectomy — whether contralateral or bilateral — can reduce the risk for breast cancer occurrence in women at high risk by nearly 95%.

Listen as Helen Krontiras, MD discusses UAB’s Lynne Cohen Preventive Care Program for Women's Cancer, which provides comprehensive risk assessment and prevention for breast, ovarian, and uterine cancer, arming patients with knowledge to make informed decisions about their cancer risk and care.
Preventative Mastectomy
Featured Speaker:
Helen Krontiras, MD
Helen Krontiras, MD ia a Professor of Surgery, Clinic Director, UAB Breast Health Center, Co-Director Lynne Cohen Prevention Program for Women.

Learn more about Helen Krontiras, MD 

Dr. Krontiras has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity.
Transcription:

Melanie Cole (Host): During the last 40 years, researchers have demonstrated the prophylactic mastectomy whether contralateral or bilateral, according to the NIH, may reduce the risk for breast cancer recurrence in women at high risk by nearly 95%. My guest today is Dr. Helen Krontiras. She's the Medical Director of the UAB Multidisciplinary Breast Clinic. Welcome to the show, Dr. Krontiras. This has become an area of some controversy, so let's begin with genetic testing and who do you advise get tested for the bracket mutation?

Dr. Helen Krontiras (Guest): That is a great question and I think given the recent events in our popular literature and in the press, there's a little bit of confusion about that. Well, first of all we recommend that people who have a very strong family history be tested and, specifically, strong family history of breast cancer that is diagnosed in younger patients and we also recommend that the genetic testing be first done, if available, in a relative who’s had cancer. So, we prefer to test an affected relative first and that allowed us to get the most information about that family and whether or not a mutated gene might be responsible for cancer in that family. So, if this patient does have a personal history of breast cancer, we look to test those patients who have an age of onset of their breast cancer is less than 50; if they have a certain type of breast cancer called triple negative breast cancer, we usually use the age of 60 as that cut off; and then, if they have multiple primary breast cancers within the same breast or within the other breast, that can also increase the probability that there is a gene in the family that may have predisposed them to cancer. If they have relatives, first-degree relatives of breast cancer less than the age of 50, more than one relative on the same side of the family who has had breast cancer and or pancreatic cancer or ovarian cancer, all of those cancers can run together in the familiar similar breast cancer syndromes that we are talking about. If there is a male in the family who has breast cancer or if the patient themselves is a male, we would recommend genetic testing. Obviously, finally, if there was a mutation known to be in the family, then we would recommend the relative of that person to be tested.

Melanie: Are the mutations of BRCA1 and BRCA2 more common in certain racial and ethnic populations than others?

Dr. Krontiras: They are, so the Ashkenazi Jewish heritage can increase the risk for a genetic predisposition to breast cancer and would be another reason to test for the gene. Again, specifically, we would prefer to test in an affected relative; if that relative was unavailable for testing, then we would test the unaffected relative.

Melanie: Dr. Krontiras, what other cancers have been linked to these mutations?

Dr. Krontiras: So, my job discus pancreatic cancer and ovarian cancer in males, prostate cancer can also be associated with BRCA1 and BRCA2. Nowadays, we're also testing for a lot of other types of genes, some of these genes don't have the same penetrance as the BRCA1 and BRCA2 do and there are other cancers that are associated with those and so a lot of times, given a patient's family history, a genetic counselor may choose to test not just for the BRCA1 and 2 genes but for a panel of genes that that patient may be at risk for. That requires the kind of writing out a pedigree to really determine what the pattern is and what genes may fall into that pattern and have the patient have a full test for that, for those genes that may be also predisposing them to breast cancer.

Melanie: So, speak about the discussion that you and other Physicians might have with their patients, if they get this genetic test and test positive.

Dr. Krontiras: So, it is a lot of information for patient to kind of get all at one time and what I recommend to the patient is really to get as much information as they can and to not rush to make any decisions immediately with the information. I think it's time for the patient just to gather information and make the best decision for themselves. But, what I tell them specifically if that having a BRCA 1 or 2 mutations, deleterious mutation does significantly increase the risk for them to develop breast cancer and is probably the biggest risk factor or the most significant risk factor that we know about today. So, it is a substantial risk that is afforded to the patient as a result of the BRCA1 or 2 gene and so I counsel them about how to manage that; first to gather more information and then secondly, for management strategies and the first strategy is surveillance. To patients who have an increased risk for developing breast cancer based on the BRCA1 or 2 genes, we recommend that they have increased surveillance and that surveillance would include a mammogram, a physical examination and probably even a breast MRI and those things to be done at least annually, if not more frequently based on their current situation but for sure those things should be done annually. Here at our institution, we recommend that those things be done and an offset each other so that patient has a mammogram at one time of the year and then an MRI at another time of the year. Now, these surveillance measures do not prevent breast cancer from happening but they try to find them early when the cancers or are most likely to be curable. So, they don't prevent breast cancer from happening and so for a patient, while she's trying to make a decision about how to manage the risks in an active way, she can undergo surveillance and have a good chance of identifying cancer at an early stage. And then, the next intervention is called “chemo prevention” and chemo prevention is taking a drug to help reduce the risk of developing breast cancer. We have available to us several estrogen blocking type medications. Tamoxifen was the first one that was approved for this purpose and these drugs can reduce the risk of developing breast cancer in women who are at increased risk by 50 or 60%. We don't have a lot of data about specific risk reduction in the BRCA population, but we do feel that since the BRCA2 gene is often associated with estrogen receptor-positive tumors that taking a chemo-preventive drugs like Tamoxifen or another estrogen type blocker, that these medications could reduce the risk for these patients. Certainly, this could be, again, and interim step as the patient was trying to decide what the best risk reduction method for them would be. And then, finally prophylactic surgery and prophylactic surgery for BRCA1 and 2 positive patients include the prophylactic mastectomy to reduce the risk of breast cancer and prophylactic oophorectomy which reduces the risk for breast cancer and ovarian cancer in premenopausal women. So prophylactic oophorectomy can reduce the risk for breast cancer, when done in the premenopausal setting and can reduce the risk by 50% and, as you indicated, a prophylactic mastectomy can reduce the risk of up to 90 - 95% and is the method that I would say, at least at our institution, that most women choose to go that route, but we do have women who choose not to, and who choose to have chemo prevention or who choose to have surveillance and I think those are very reasonable options for those patients. There is a little bit different between the two genes, BRCA1 and BRCA2. I mentioned earlier, with BRCA2, often most of those tumors are going to be related to an estrogen positive tumor, but not all of them. BRCA1 is little bit different; 80% of the patients who have a BRCA1 mutation and go on to develop cancer, breast cancer, will develop a triple negative breast cancer which is often more aggressive and can sometimes be more aggressive even at a smaller stage. That makes that population have cancers that are a little bit more worrisome, if they occur. All cancers, no matter the type, when diagnosed at an early stage, will have a good prognosis

Melanie: So are the bilateral or contralateral prophylactic mastectomies similar in their outcomes? Are there slightly different? How does that work for patients?

Dr. Krontiras: So, in a patient who has breast cancer and chooses to have a mastectomy for treating that a unilateral mastectomy is often all that is medically necessary. A prophylactic mastectomy of the other breast or the contralateral mastectomy is to reduce the risk of cancer that the patient may or may not develop in the future and if you have a BRCA 1 or 2 gene, that risk is going to be higher than that of the general population, so oftentimes, patients who present with breast cancer and have a known mutation, will choose to have the contralateral breast removed.

Melanie: So, in the efficacy of contralateral prophylactic mastectomy, afterward do they still need screening?

Dr. Krontiras: Well, that’s a great question question and I would say, for the most part, there is really no evidence to indicate or to recommend for any type of imaging screening after prophylactic mastectomy that is done for prophylactic intent in the modern-day practice a prophylactic mastectomy. Long ago, patients would have subcutaneous mastectomy for prophylaxis and that would leave a lot of breast tissue behind, but in the modern-day practice of prophylactic mastectomy, that is not the case and that would not be a standard or acceptable operation for prophylaxis. So, in the standard practice of prophylactic mastectomy, there really isn't any standard indication for any Imaging to be done routinely after prophylactic mastectomy. There are some recommendations for the plastic surgery colleagues in patients who have silicone-based implants that perhaps they should have MRI screening for the integrity of the implants on a regular basis, but outside of that, there really isn't any definitive recommendation for anything specific imaging for asymptomatic patients for screening. Now, we do have patients at our institution who have had prophylactic mastectomy to have an annual clinical breast exam and a lot of them choose to come to the breast specialist for that purpose. So, in our practice an annual clinic breast exam is really what is recommended to our patients you have prophylactic mastectomy and, obviously, if they have any symptoms then they would, we would work those symptoms up because patients don't have, it's not a 100% risk reduction. It is, you know, 90 - 95% risk reduction, so there is a possibility that they could develop cancer in the future but it is a very small percentage.

Melanie: In the last few minutes, Dr. Krontiras, how can a community physician refer patient to UAB medicine?

Dr. Krontiras: So, that can be accomplished very easily. We have a risk and prevention program where we see women who are at increased risk for a genetic mutation or who have a known genetic mutation and we have a program for them where we can discuss with the patient their risk and talk about the magnitude of the risk, talk about ways to reduce the risk including even lifestyle modifications, which we know, have a big impact on that, on their risk. So, patients or their doctors, could call the clinic and be referred for evaluation in our risk and prevention program.

Melanie: Then tell us about your team. Why is UAB so great to work with?

Dr. Krontiras: Well, we do have an excellent team and I would say that the team of nurses and doctors and staff that we have here in the breast health center are here not just because it's a job; it’s because of the patient and they really come to work every day with a strong heart to take care of the cancer patients and even the prevention patients that we see here and it is more of a calling for them and I think that makes them excellent caregivers and make them relate to the patient so much more. They treat every patient like it was their mother or their sister.

Melanie: Thank you so much for being with us today Dr. Krontiras. You're listening to UAB Medcast and for more information and resources available at UAB medicine, you can go to www.UABmedicine.org/physician. That's www.UABmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.