Surgical Management of Breast Cancer in BRCA Mutation Carriers

Abstract

Breast cancer is a group of genetically distinct diseases with differing responses to treatment and varying patterns of both local and systemic failures. This recognition has led to many questions regarding the optimal surgical management for those considered to be high risk. There is no consensus on what constitutes the best surgical management of primary breast cancer in BRCA mutation carriers. Several aspects need be considered during the surgical decision-making process: the risk of ipsilateral breast tumor recurrence (IBTR), the risk of ipsilateral new primary breast cancer, the risk of contralateral breast cancer (CBC), the potential survival benefit of prophylactic mastectomy (CPM), and other treatment or patient factors that could modify the risk for IBTR or CBC. Mutation carriers with unilateral breast cancer should be counseled on a case-by-case basis. Breast-conserving surgery with adjuvant radiation, therapeutic mastectomy, or therapeutic mastectomy with concomitant CPM could be utilized for surgical management. Patient age, stage of the index lesion, and individual patient preferences should all be considered in the decision-making process. Use of adjuvant chemotherapy and/or endocrine therapy and oophorectomy can modify risks of IBTR and CBC. However, the available evidence can guide risk/benefit discussions of surgical options and may help identify subgroups of patients who may be at higher risk for IBTR or CBC that may benefit from a more aggressive surgical approach.