With available tests for breast cancer risk genes, some women learn at a young age that they have a high lifetime risk of developing breast cancer. Plastic surgeons play a key role in advising and managing this group of young, high-risk adults. This emerges from a special topic in the June issue of Plastic and Reconstructive Surgery the official medical journal of the American Society of American Society of Plastic Surgeons (ASPS).
"Young BRCA-positive patients undergoing mastectomy have unique surgical and psychosocial needs," commented ASPS member surgeon Nolan S. Karp of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health, New York , "Plastic surgeons need to be familiar with the treatment guidelines, the necessary referral patterns and the special needs of these patients to adequately manage their care."
Even for women with BRCA risk genes, low breast cancer risk before the age of 30
Dr. Karp and colleagues share their insights from working with young women seeking BRCA (breast cancer-associated) genetic testing for a family history of breast cancer. In recent years ̵
Patients undergoing a risk-reducing mastectomy undergo the highest rate of immediate breast reconstruction. This means that plastic surgeons, along with other specialists such as breast surgeons, oncologists and genetic counselors, play an important role in their care.
Because BRCA and other genes pose a high lifelong cancer risk, young women with a family history of breast cancer may feel that they should be tested as early as possible. However, current guidelines recommend that BRCA mutation screening be conducted only when women are 18 years old, the "age of consent". While BRCA mutations are responsible for two to ten percent of breast cancers, they are only present in 0.2 to 0.3 percent of the total population.
Fortunately, the absolute risk of developing breast cancer in young women is low – only about 1.5 to 3.4 percent at the age of 30, depending on the mutation. Although tested, young women may find themselves in a "clinical limbo" as breast cancer reduction is usually not recommended until the age of 25 years.
Decisions on BRCA testing are not necessarily straightforward. While testing can have negative psychological consequences, some women may be in distress because of the uncertainty about their risk – which could be alleviated by testing. Tests can also influence important life choices, including reproductive planning.
The decision should be based on the maturity of the individual, the ability to process information, and make informed decisions, not just on age. Dr. Karp and colleagues write: "Adult adult empowerment and maturity is an evolving process and must be handled carefully for lifelong implications."
Even if BRCA or other risk genes exist in young women, there is usually no urgency to perform a risk-reducing mastectomy. Although surgery can reduce pain and anxiety, mastectomy itself can have negative physical and psychological consequences. At any age, patients need to understand that while mastectomy can reduce risk by almost 90 percent, it does not completely prevent the risk of developing breast cancer
Applying nipple-sparing techniques, followed by immediate reconstruction – on most common with implants – has increased the acceptance of risk-reducing mastectomy in young women. Immediate reconstruction reduces mental stress and problems with body image and sexuality.
Due to the high public awareness of risk-reducing mastectomy and breast reconstruction, plastic surgeons are sometimes the first physicians to target young women at high risk of developing breast cancer. Dr. Karp comments, "Seamless communication between multidisciplinary teams is essential to make evidence-based decisions for these patients."
The risk of a second breast cancer can be better quantified in women who carry a BRCA mutation
Ara A. Salibian et al. BRCA mutations in the young, high-risk female population, Plastic and Reconstructive Surgery (2018). DOI: 10.1097 / PRS.0000000000004363