Surgical management of the patient at high risk for breast cancer

The most controversial aspect of breast disease centres around the management of patients who have either a strong family history of breast cancer or a biopsy diagnosis of lobular carcinoma in situ or ductal carcinoma in situ. The current alternatives for patients who have two or more relatives with breast cancer consist of close follow-up or prophylactic total mastectomies and reconstruction. Invasive breast cancer in patients with lobular carcinoma in situ may occur in either breast and may be as high as 30% at 20 to 30 years. In these women it is reasonable to do a wide excision of the lobular carcinoma; in those without a family history, close follow-up is adequate. Intraductal cancer treated by biopsy only is associated with a 40% risk of cancer in the ipsilateral breast. Therefore, the usual management is total mastectomy. However, the information to support this therapy over a segmental resection has limited scientific validity. Because the cosmetic appearance after total mastectomy and reconstruction is not as good as that of the normal breast, this procedure must be employed cautiously and only with the total support of the patient and her husband or close family. Subcutaneous mastectomy for prophylaxis leaves behind macroscopic glandular tissue and, therefore, is not considered by many to be optimal management. A total mastectomy, preserving the skin and resecting all macroscopic breast tissue and nipple, is the treatment of choice if the procedure is deemed appropriate.