Risk Reducing Surgery

Women who are at high risk of developing breast and ovarian cancer may decide to undergo risk-reducing surgery in conjunction with their healthcare team.

Risk reducing surgery removes body tissue that is most likely to be at risk for cancer, and can be used for both breast and ovarian tissue. Such surgeries can greatly reduce your risk. Undergoing these surgeries is a big and very personal decision, and must be discussed in length with your healthcare team.

“Deciding whether or not to have such a big and drastic surgery is daunting, scary and overwhelming. Making the decision to take control of my future and decide what I was taking control of the driver’s seat was the scariest but best decision I ever made. – Alex.”

Breast Surgery

Risk-reducing breast surgery (removal of both breasts which is called bilateral mastectomies) is an option for women who have a high lifetime breast cancer risk.

Most women also have reconstruction of their breasts in a process that starts at the time of the breast removal (mastectomies). There are various types of reconstruction available. What works best for you will depend on many factors including body type and recovery options. You and your surgeon are best placed to discuss the best options for you.

Some helpful questions that you could ask your surgeon include:

  • What are the different types of reconstruction available and how are they done?
  • Which approach would you recommend for me and why?
  • Can I have nipple reconstruction? How are they created?
  • What sort of implants can be used?
  • Can I choose the size of the reconstructed breasts?
  • Can I see any pictures of breasts before and after reconstruction?
  • What will the scars look like?
  • Will I have any feeling or sensation in my reconstructed breasts?
  • Is breast reconstruction covered by Medicare?
  • What are the costs?
  • Do I still need to have breast screening?
  • Will breast reconstruction interfere with breast screening?
  • Can mammography damage a breast implant?
  • If I do get breast cancer, would scar tissue or a breast reconstruction make it difficult to detect?
  • How long would I have to wait before I can have the procedure done?

Risk Reducing Mastectomies
A mastectomy is the medical term for the surgical removal of one breast. Mastectomy is usually done to treat breast cancer. Risk-reducing mastectomies is the term for the removal of both breasts to minimise risk of cancer developing in breasts that do not currently have cancer. This is sometimes also called bilateral prophylactic mastectomies.

In a small percentage of women who undergo this surgery, breast cancer is found at the time of surgery or when the tissue is sent to the pathology laboratory to be checked.

When deciding whether risk-reducing mastectomies are right for you, it is important to know what’s involved. Talking to a breast surgeon and reconstructive surgeon about your particular situation is the best way of finding out what the surgery may involve and what it means for you.

Types of mastectomies
There are a number of different types of mastectomies. These include:

  • Total mastectomies – A total mastectomy involves removing as much of the breast tissue as possible. The nipple, the coloured skin around it (called the areola) and most of the skin covering the breast is also removed.
  • Skin sparing mastectomies -This approach involves removing as much of the breast tissue as possible, as well as the nipple and areola. The skin that was covering the breast is preserved, making it easier to maintain the contour of the breast when reconstruction is done.
  • Nipple-sparing mastectomies – In this procedure, as much of the breast tissue as possible is removed while leaving in place all the skin, the nipple (which contains breast ducts) and the areola. This can leave slightly more tissue behind than with total or skin-sparing mastectomies. Sometimes, a procedure called nipple delay is done 1-3 weeks before the mastectomies. In this procedure, the blood supply to the nipple from the underlying breast tissue is cut so that the nipple gets used to being supplied by blood vessels from the surrounding skin instead. This can help reduce the risk of tissue death in the nipple when the mastectomies are done. A biopsy of the tissue under the nipple can be done at the same time as the nipple delay surgery to check that there are no cancer cells in the nipple.

How much cancer risk is left after risk-reducing mastectomies?
In theory, if all the breast tissue is removed, a woman’s risk of developing breast cancer should be eliminated. In practice, all the breast tissue that can be seen by the surgeon is removed. Unfortunately, it is not possible to remove every single breast cell, so there is still a small risk (2-5%) of developing breast cancer after risk-reducing mastectomies. As with any surgery, everyone responds differently to mastectomies. Most side effects can be reduced or managed with appropriate care.

Side effects
Common side effects of mastectomies include:

  • Pain, discomfort or numbness in the breast and/or armpit while the wounds are healing. This usually settles after a few weeks.
  • Fluid may collect in or around the scar in the breast or armpit. This is called a seroma and may need to be drained using a fine needle and a syringe. This can be done by a breast care nurse or another health professional in the clinic or by a GP.
  • Stiffness in the arm or shoulder. It may be helpful to do some approved exercises after surgery.
  • Numbness or tingling in the arm or shoulder if lymph nodes have been removed. This may improve with time, but feeling in these areas may change permanently.
  • Mild pain in the armpit or upper arm. This can last a year or more after surgery if lymph nodes have been removed.

Side effects that sometimes develop after mastectomies include:

  • Swelling or bruising around the wound in the chest or armpit. This usually settles in a few weeks.
  • Bleeding and infection.
  • If lymph nodes have been removed, there may be swelling in the arm, breast, hand or chest that lasts after the initial side effects of surgery are over. This is called lymphoedema and can develop a few months or years after surgery.

Breast Reconstruction
Breast reconstruction is a procedure where the breast is rebuilt either using implants, tissue from another part of the body or a combination of both techniques. It is performed by a breast and/or plastic surgeon with expertise in breast reconstruction.

However, reconstruction after mastectomies to reduce cancer risk is not the same as having surgery to enlarge the breasts for cosmetic reasons. After risk-reducing mastectomies and reconstruction the breast will look ‘lifelike’ under clothing but may actually look and feel different to how it did originally.

There are different types of reconstruction procedures available. You will be given options and your preference may depend on the amount of time you have to allow for being in hospital and the recovery time when you will not be able to lift things, do housework and drive.

Although your preference is important, the type of surgery and method used will depend on many additional factors, some of which include your weight, body shape (and whether or not you are a smoker, as this affects tissue healing). Other health issues such as diabetes or auto-immune conditions (e.g. lupus) can also affect tissue healing. In addition to talking to your surgeon about reconstructive options, you may also find it useful to talk to other women who have had surgery to have a realistic expectation about the results.

Here is a brief introduction to the different types of reconstruction, followed by a section that sketches the pros and cons of each approach.

Implants
Breast reconstruction using implants involves rebuilding a breast shape by inserting a breast implant under the skin and muscle on the chest. There are two main types of implant surgery- tissue expanders and direct to implant.

Tissue Expanders – Before inserting the implant, a special bag, called a tissue expander, is inserted underneath the muscles on the chest wall at the mastectomy surgery. Over the next few weeks or months, fluid is injected into the bag about once a week to stretch the muscle and skin. When the expander bag has reached the right size, a second operation is performed to remove the bag, and the permanent implant is inserted.
Direct to Implant – This procedure involves inserting the permanent implant at the time of the mastectomy surgery.

For further information see Cancer Australia.

Tissue Reconstruction
DIEP Flaps
This technique is generally preferred for tissue reconstruction. A deep inferior epigastric perforator (DIEP) flap breast reconstruction rebuilds a breast shape by moving skin and fatty tissue from the abdomen (tummy) to the chest. (The DIEP term is the name of the blood vessels that provide blood supply to the tissue that is moved). A woman must have enough abdominal (tummy) fat but also not too much. No abdominal muscle is used in this procedure. For further information see Cancer Australia.

TRAM Flaps
Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction involves rebuilding a breast shape by moving skin, fatty tissue and part of the rectus abdominis (tummy) muscles from the abdomen (stomach) to the chest. The rectus abdominis muscles run from waist to pubic bone (and are sometimes called ‘6 pack’ muscles). For further information see Cancer Australia.

Latissimus Dorsi Flaps
Latissimus dorsi (LD) flap breast reconstruction involves rebuilding a breast shape by moving skin, fatty tissue and muscle from the back (where the LD muscles are below the shoulder blades) to the chest. Tissue expanders (which are later replaced with permanent implants) are sometimes also used to create sufficient breast size. For further information see Cancer Australia.

Nipple and Areola Reconstruction
It is possible to reconstruct a nipple after breast surgery. This can be done using skin from the breast or tissue from another part of the body. The area around the nipple can be coloured to match the other breast using a tattoo.

The reconstructed nipple usually does not have any feeling. Some women prefer to use a nipple prosthesis, which can be attached to the reconstructed breast using special glue. For further information see Cancer Australia.

Fat Grafting
In fat grafting (also called autologous fat transfer), fat tissue is removed from other body parts, usually thighs, belly and buttocks, by liposuction and injected into the breast area. This procedure is relatively new so no large studies have been done on this technique and it is not widely offered.

Advantages and Disadvantages of Different Types of Breast Reconstruction
Breast reconstruction surgery recreates the shape of the breast following a mastectomy or breast conserving surgery. It can be done at the same time as your surgery (immediate reconstruction) or as a separate procedure at a later time or even at a much later date.

You will need to talk to a plastic surgeon regarding your reconstruction. There are of course advantages and disadvantages to this surgery.

Implants
Advantages of this operation are relatively simple:

  • hospital stays and recovery periods are usually quite short
  • surgery and scarring is only in and around the breast area

Disadvantages include:

  • the reconstructed breasts may not be as natural looking (when unclothed) as with other types of breast reconstruction. With clothes on, however, your breast shape will look ‘lifelike’
  • scar tissue can form around the implants making the breasts feel firm and uncomfortable
  • the implants may have to be replaced later, or removed if there is an infection

DIEP Flaps
Advantages include:

  • it produces the most natural looking breast
  • the reconstructed breast will change in size if the woman gains or loses weight
  • there is less risk of abdominal wall weakness and hernia compared to the TRAM procedure as the abdominal muscle is not used for reconstruction
  • quicker recovery than the TRAM procedure as the abdominal muscle remains intact

Disadvantages include:

  • the woman will have a scar across her stomach
  • there is a small risk the tissue moved to the chest will not ‘take’, meaning the tissue will die and if this happens another operation will be needed
  • the hospital stay and recovery time will be longer than with implant-only reconstruction
  • the woman will not be able to drive or lift heavy objects for several weeks after surgery

All surgery has a risk of complications. The main possible complications are infection, bleeding and/or a blood clot forming in the leg (known as deep vein thrombosis or DVT), which may then lead to a blood clot on the lung (called a pulmonary embolus). These are rare and clinicians will make every effort to prevent them.

As with all surgery that requires a general anaesthetic, there is a very small risk of other more serious complications such as chest infection or even death. These risks are low in breast surgery, although they are slightly increased in women who have heart or lung conditions or diabetes.
Possible complications should be discussed with your surgeon and anaesthetist.

TRAM Flaps
Advantages include:

  • it produces a natural looking breast
  • the reconstructed breast will change in size if the woman gains or loses weight

Disadvantages include:

  • the woman will have a scar across her stomach
  • the woman could lose strength in her stomach muscles
  • the woman may be at risk of developing a hernia
  • there is a small risk the tissue moved to the chest will not ‘take’, meaning the tissue will die and if this happens another operation will be needed
  • the hospital stay and recovery time will be longer than with implant-only reconstruction
    the woman will not be able to drive or lift heavy objects for several weeks after surgery

Latissimus Dorsi Flaps
Advantages include:

  • it produces a more natural looking breast than implant-only reconstructions
  • the reconstructed breast will change in size if the woman gains or loses weight

Disadvantages include:

  • the woman will have a scar on her back
  • there may be some loss of strength in the arm
  • there is a small risk the tissue moved to the chest will not ‘take’, meaning the tissue will die. If this happens another operation will be needed
  • the hospital stay and recovery time will be longer than with implant-only reconstruction

Gynaecological Surgery

When thinking about risk-reducing gynaecological surgery, it is important to know what’s involved and who can help you gather your facts. Your Familial Cancer Clinic team can advise you about your level of risk and the age at which it is increased. You can then start to make a plan by talking to a surgeon with expertise in gynaecological cancer risk management. Speaking with a psychologist about how you are thinking about the pros and cons can also help, as can talking with other women who have faced similar questions. For some women, the wish to complete their family can be a pressure if they are reaching an age at which risk-reducing surgery is being recommended. Talking with a fertility specialist may also be helpful.

Risk-reducing salpingo-oophorectomy
Risk-reducing salpingo-oophorectomy (RR-SO) is the surgical removal of the ovaries and the Fallopian tubes which connect the uterus (womb) with the ovary. Both types of tissue are at increased risk in women with a family history of ovarian cancer or an ovarian cancer risk gene mutation. RR-SO is the most effective way to reduce risk in these tissues, to levels of less than 5% (5 in 100). There is no effective way to screen for ovarian or Fallopian tube cancer.

Risk-reducing surgery is usually recommended at around age 40 years, as risk before then is low. Sometimes, removal of the uterus (hysterectomy) may be done at the same time. This might be considered in specific situations, for example, if a woman has uterine problems that are causing symptoms. Uterine cancer risk is not increased by a family history of breast or ovarian cancer or a breast-ovarian cancer gene mutation. Adding hysterectomy to the RR-SO does make this a bigger operation with some increased risk of complications and longer recovery time.

Removal of the Fallopian tubes alone (salpingectomies) is not an adequate long term cancer risk reduction treatment. If a woman has had her Fallopian tubes removed and has a high ovarian cancer risk (due to a family history of ovarian cancer or a mutation), she will still be advised to have her ovaries removed.

What about side effects of a risk-reducing salpingo-oophorectomy?
Once the ovaries are removed, there is only a small amount of oestrogen still made outside the ovaries, in other tissues. This means that a woman will be in menopause, but it is not possible to predict who will have symptoms and who will not. It is important to know that there are options to manage symptoms, including hormone replacement. So far, it seems that HRT used for a few years in a woman who has had RR-SO before age 50 does not increase breast cancer risk. Advice on HRT may vary with the woman’s level of breast risk, whether she has had breast risk-reducing surgery, the type of HRT and the amount of years it is used.

HRT can help manage symptoms of menopause, in particular, hot flushes. Other benefits of HRT include protection against osteoporosis. There are other medications that can assist with symptoms and there are specialist Menopause Clinics and other resources (such as jeanhailes.org.au). You can still have a healthy vigorous life after risk-reducing gynaecological surgery but it is important to know how you can deal with any side effects if they do happen.

How is the surgery done?
In most cases, the surgery can be performed using laparascopic (keyhole) surgery. This involves three to four small (1-2cm) incisions (cuts) in the skin of the abdomen (tummy) which are closed with a stitch or surgical tape. This form of surgery usually involves staying in hospital overnight and going home the next day. In some situations, an open operation through a larger incision (laparotomy) will be recommended. Your surgeon will discuss this with you prior to the surgery.

After the surgery, there will be some pain in the abdominal (tummy) wall, that may feel like a torn muscle. Less commonly, there is pain in shoulder which is due to the abdominal lining being irritated, but this will usually go within 24 hours. For most women, any pain is usually well controlled with regular paracetamol and an anti-inflammatory medication such as ibuprofen for 2 – 5 days. Occasionally a stronger pain medication such as codeine or oxycodone may be required for one to two days. If you have severe pain that is not controlled by these types of medication, you should contact your surgeon or the hospital, so they can investigate the cause and manage it.

You should be mobile and able to do your normal living activities when you leave hospital. You will be unable to do strenuous activity such as heavy lifting, driving or going to the gym for about one week. You can usually resume light gym activity and return to work after about seven to 10 days, but you will need to be guided by your surgeon. Recovery time will be longer if your operation was not done laparoscopically.

What about follow up?
A follow up appointment is usually arranged for about six weeks after surgery. Before discharge from hospital, make sure you confirm with your surgeon when and how the pathology results from your operation will be given to you. The tissue that is removed is sent to a laboratory after surgery to make sure that no ovarian cancer was already present (which is very uncommon). It is important the tissue is checked carefully by an expert pathologist.

Click here to refer to the FAQ’s on Risk Reducing Surgery.

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