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Preventive mastectomy: surgery

Preventive mastectomy: surgery

Synonym (s): adenomastectomy, prophylactic mastectomy, double preventative mastectomy

What is preventative mastectomy?

Preventive mastectomy is a cancer prevention surgery of breast. Preventive mastectomy surgery consists of the removal of the internal breast region - that is, the mammary gland together with the mammary ducts - which are the places where a tumor may form. With the removal of the inside of the breast, the risks of cancer reduce by up to 90%. The chances of cancer still exist because 10% of the breast tissue is still preserved to nourish the skin, halo and nipple. In surgery, both breasts will be removed, hence the name of double preventive mastectomy. Breast cancer is the most common form of cancer in the world, with 1.38 million new cases and 458,000 deaths each year, according to the World Health Organization. In Brazil, the Ministry of Health estimates 52,680 new cases in a year, with an estimated risk of 52 cases per 100,000 women.

Indications

According to data from the Brazilian Society of Mastology, about one in 12 women will have a tumor in the breasts until the 90 years of age. However, preventive mastectomy is indicated for women who are at high risk for this disease. The criteria for identifying the risk in a woman are:

  • Personal history of breast cancer: women who have had cancer of one breast can undergo surgery to reduce the risk of recurrence.
  • Strong family history: two or more first-degree relatives with breast cancer
  • a first-degree relative and two or more second- or third-degree relatives with the disease
  • two first-degree relatives with breast cancer, one of whom had the disease before aged
  • a first-degree relative with bilateral breast cancer
  • a first-degree relative with breast cancer and one or more relatives with ovarian cancer
  • a second or third degree relative with cancer of breast and two or more with ovarian cancer
  • three or more second or third degree relatives with breast cancer
  • and two second or third degree relatives with breast cancer and one or more with ovarian cancer
  • Genetic mutations: the woman has a mutation in the gene BRCA1, BRCA2 and p53, both indicative of high risk for breast cancer. To discover this mutation, a genetic mapping test is required, in which a blood or saliva sample is taken for DNA analysis in the laboratory. Genetic testing should be considered mainly by patients where there is a very precise indication, with a strong family history, such as women who have cases of breast and ovarian cancer in the family and are of Ashkenazi Jewish ancestry. with risk lesion: intralobular neoplasia, intraductal carcinoma and atypical epithelial hyperplasia. The identification of these lesions is done by means of CT scans and magnetic resonance imaging during routine follow-up with a professional.
  • Prerequisites for surgery

There are no mandatory pre-requisites for preventive mastectomy, it is sufficient to have a high risk for breast cancer. However, doctors recommend preventive mastectomy only for women who already have established offspring - that is, they already had all the children they wanted. This is because, after the surgery, the woman will not be able to breastfeed anymore because the mammary glands will be removed. If a first-degree relative has suffered from the disease, the ideal is that the mastectomy be done before the patient reaches the age at which her relative had breast cancer. An example: if the patient's mother or sister had breast cancer at age 40, the patient is advised to have a mastectomy before reaching that age, ensuring prevention.Patients who are at greater risk of postoperative, such as smokers, women with obesity, and difficulties and comorbidities, such as diabetes and hypertension, have the qualifications to perform preventive mastectomy and may therefore be contraindicated in some cases. Remembering that only a doctor will be able to do this restriction.

Which doctor performs the surgery?

Preventive mastectomy surgery is done by a mastologist. However, a multidisciplinary team, including a plastic surgeon, is recommended to perform breast reconstruction, and a psychologist to follow the entire process of breast removal, from medical consultation to post-surgery, to avoid possible emotional sequelae to the patient.

How is preventative mastectomy performed

Cutting is done at the base of the breast, where the mammary gland is withdrawn - Photo: Getty Images

To perform the mastectomy, the mastologist makes a cut across the base of the breast, and through this incision removes the entire mammary gland, preserving only the pectoral muscle and skin, along with halo and nipples. If the woman chooses to do a breast reconstruction, the plastic surgeon will, in the same procedure, make the silicone implant or put expander bags, filled with saline, that only prepare the breasts to receive the silicone prosthesis in a future procedure. In cases of very large breasts or with leftovers, a joint surgery is performed to remove tissue, so that the silicone prosthesis is not too large and as natural as possible, avoiding deformations. risk of necrosis, the patient may undergo an autonomic nipple, which consists of making a small incision in the lower part of the nipple or its entire border, to separate it from the mammary gland and to stimulate the blood supply in the area.

Types of anesthesia

General anesthesia is given to ensure that the patient is disrupted during the entire surgery.

Procedure time

The length of time a preventive mastectomy will last depends on the size of the breasts, whether it will be breast reconstruction and the progress of surgery. The doctor needs to make sure that both breasts look the same, and this may take more or less time depending on the case. A preventive mastectomy can last for two hours, as it can take anywhere from six to eight hours without complications - it all depends on the conditions of the patient and the variants cited.

Length of hospital stay

The preventive mastectomy patient can stay from four to seven days in the hospital, according to the intensity of the surgical procedure.

Exams necessary to perform surgery

All preoperative exams, including cardiology and electrocardiogram.

Pre-procedure care

The patient needs to perform a 7-hour fasting required to perform preventive mastectomy. Complications that may occur are inherent in any surgical procedure such as infection, bleeding, inflammation, and rupture of suture. . If it occurs, the treatment is the same as any other wound. Surgery can cause emotional sequelae because of the trauma of having the breast removed, because even with reconstruction, the feeling of loss and loss of self-esteem should be worked out. More specific risks involve necrosis of the breast and halo and deformation of the silicone prosthesis.

There is also a chance that the patient will not be happy with the result of the preventive mastectomy. In some cases, may the breast not be exactly the same as it was, with changes in size or shape? especially in cases where the breasts were very large or flaccid, requiring surgery to reduce and remove the skin. According to the Brazilian Society of Mastology, about 30% of the women who do the procedure are not happy with the result regarding the appearance of the breasts.Post-Surgical Treatments

The woman who did the preventive mastectomy needs to continue taking CT scans, ultrasonography, and MRI along with her doctor because there is still a risk of breast cancer. Patients should also perform self-examination monthly, in addition to performing the touch examination with a specialized physician (gynecologists and mastologists) annually on their routine gynecological exams.

How is patient recovery

The post-operative Mastectomy is very painful and uncomfortable. The limitation of movement is great and depends on rest for everything to work out. In addition, there is discomfort in cases where patients are not happy with the reconstruction.

Care after surgery

After the preventive mastectomy, a rest period of seven to fifteen days is indicated. The breasts should be examined monthly by the physician, and any change in the temperature or color of the skin should be reported immediately. The wound dressings should be changed daily and the area sanitized. The use of contraceptives or beauty products based on hormones should only be used with medical authorization.

Costs of the surgery

Some Brazilian health plans cover, by proving the family history and the probability of the presence of the mutation.

Regulation

Preventive mastectomy is regulated and recognized by the Federal Council of Medicine and the National Agency of Sanitary Surveillance (ANVISA).

Expectations

A study by the Mayo Clinic in the United States tracked 639 women at risk for breast cancer, 425 at moderate risk and 214 at high risk for the disease, and found that women who had preventative mastectomy and had cancer reduced in 80% the risk of death from the disease, when compared with women who did not have a mastectomy. In addition, the procedure reduced the risk of death from disease by 2.4 to 4%, when the group was compared with both women who did not have cancer and those who did.

In Brazil, mortality rates for breast cancer remain high, most likely because the disease is still diagnosed in advanced stages. According to the Brazilian Society of Mastology, the average survival after five years of the diagnosis of breast cancer is 61% for the general population. Therefore, more important than preventive mastectomy is the follow-up with the doctor for the early detection of breast cancer, whether or not the surgery was done.

Frequently Asked Questions

A person who has a proven risk for breast cancer Does breast cancer need to undergo surgery, or can it have another type of follow-up?

A woman at high risk for breast cancer may choose not to have a preventive mastectomy. There are treatments that use so-called anti-hormones or hormone modulators, which inhibit the production of estrogen and prevent the breast cells from multiplying. This treatment, however, is only recommended for hormonal breast cancers - that is, they happen or can happen as a result of hormonal changes - not being indicated for people who have a genetic risk, for example.

For patients at risk an alternative is to redouble the attention and monitoring of the breasts, starting for screening exams such as breast ultrasound and mammograms at shorter intervals every six months for example depending on what your doctor considers safer . The objective in this case is to identify the cancer at a very early stage and to start the appropriate treatment from this diagnosis. Data from the National Cancer Institute (INCA) indicate that if the disease is detected at an early stage, the chance of cure reaches 90%.

Why is preventive mastectomy always removes both breasts and not just one?

The option is always a double mastectomy because both breasts are at risk when women have a BRCA mutation or when they have a strong family history. The removal of both breasts is done because neither the doctor nor even tests can identify which of the two breasts will present the cancer.

Who still wants to have children can do?

Preventive mastectomy does not prevent the woman from having children , but breastfeeding is no longer possible because mammary glands and breast ducts were removed. Because of this, mastectomy is advised for a woman who already has a defined offspring.

What is the percentage of breast cancers that occur because of the genetic mutation?

The general population has about 10 to 12% develop the disease. According to the Brazilian Society of Mastology, the presence of the mutation among breast cancer cases is around 5 to 10%, with 5% of all breast cancers being of women with the BRCA mutation. Therefore, the safest way to treat and prevent it is to visit your mastologist, when indicated, and follow their guidelines.

These mutations are associated with the most aggressive type of breast cancer, which is known as triple negative. Triple negative breast cancer occurs when women do not have three biomarkers (proteins that control cell functions) present in other types of cancer: estrogen (ER), progesterone (PR) and HER2 (responsible for cell growth ). Other types of breast cancer can be identified by the presence or absence of these biomarkers, as well as the location of the breast affected by the tumor.

Sources consulted:

Cristiane Nimir, specialist in pathological anatomy and responsible for the Mastology sector of Diagnostika

Hezio J. Fernandes Jr., clinical oncologist and director of the Paulista Institute of Cancerology

Walkiria Aparecida Tamelini, oncologist at Santa Cruz Hospital

Paulo Roberto Pirozzi, mastologist at Brazilian Society of Mastology Roberto Hegg, gynecologist and mastologist of the USP Hospital das Clínicas

Brazilian National Institute of Cancer

Brazilian Society of Mastology

Ministry of Health

World Health Organization


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