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Prophylactic Bilateral Mastectomy (BPM) on Moderate Risk Patients with Atypical Ductal Hyperplasia

When a woman undergoes a core biopsy and is diagnosed with Atypical Ductal Hyperplasia (ADH), the news is undoubtedly scary. Afterall, ADH is a finding of pre-cancerous cell growth which is associated with long term increased risk of breast cancer.

Some female patients respond by electing to undergo a Bilateral Prophylactic Mastectomy (BPM). Although this is a radical treatment, the Society of Surgical Oncology released a 2007 position statement asserting that BPM is justified under any of the following scenarios:

  1. The female patient is a BRCA1 or BRCA2 genetic mutation carrier;
  2. The female patient has a strong family history of breast cancer defined as having multiple first-degree relatives (mother, sister, daughter) with breast cancer; or
  3. The female patient has a high-risk histology which includes ADH.

There’s a general agreement in the medical literature that patients who carry BRCA1 or BRCA2 genetic mutations are considered high risk and would be indicated for a BPM. A meta-analysis reported that the risk of breast cancer was 65-81% for BRCA1 genetic mutation carriers and 45-85% for BRCA2 genetic mutation carriers.

However, when a patient only has a moderate family history of breast cancer and/or ADH, the risk of developing breast cancer is much lower, making the indication of BPM is less clear. The acceptable risk of developing breast cancer is a relative term that varies with the individual patient.

Before the patient elects to undergo a BPM, the Society of Surgical Oncology adds the caveat that it is best practice for the patient to first be evaluated by a multidisciplinary team of providers. This includes a surgeon, a medical oncologist, a pathologist, and a genetic counselor.

Multiple factors are associated with the risk of developing breast cancer. Examples include gender, age, histology, and genetic factors. Online risk assessment tools (such as The National Cancer Institute breast cancer risk assessment tool https://www.cancer.gov/bcrisktool/) make it easy for providers to plug in the variables and come up with a risk profile for the patient. This will allow the patient to make an informed decision about whether nonsurgical interventions are a better fit for their circumstances versus radical BPM.

For example, the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 Study found that the chemoprevention medication Tamoxifen decreased the risk of patients with ADH developing breast cancer by 86%. To put that into perspective, the New England Journal of Medicine found that the risk of moderate risk patients developing breast cancer after BPM was reduced by 89%. The risk reduction is nearly identical.

Putting aside the psychological implications of undergoing a mastectomy, there are also potential physical complications that particularly arise in the context of nipple sparring breast reconstructions following mastectomy.

In 2017, the Society of Surgical Oncology released a new position statement on BPM according to their review of the current medical literature. Notable inclusion to the risk analysis was female breast density. The message remains the same; the decision of BPM versus nonsurgical risk reduction measures should be made after the patient has a full understanding of the facts after a thorough multidisciplinary consultation.

Author: Joseph J. Russo, Esq.

Attorney Russo recently settled a complex lack of informed consent BPM medical malpractice case. If you suspect you have been the victim of medical malpractice, The Injury Law Center would be happy to discuss your case. Please contact the firm at (603) 883-4100 or info@ilcnh.com,

The above information is not intended, not should be construed as medical advice.

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