The Breast: Premalignant Organ or Functional Gland?

“It feels like I am reliving the nightmare,” the pregnant patient in my examination room said, curling her hands into a ball. “Breast cancer stole so much of my womanhood. And now it's taking away part of my motherhood.”

As a breast surgeon and lactation consultant, I am meeting more and more young women like my patient. She had undergone a bilateral mastectomy for a small right breast cancer three years prior. Now she was pregnant, grieving the loss of her ability to breastfeed.

“What can I do?” she wondered. “Is there any hope for me to produce milk?”

Unfortunately, the answer was no. A mastectomy removes >95% of the breast tissue, and precludes lactation if performed on both breasts.

As I explored other ways I could support the patient and her baby, I reflected on the challenges associated with increasing bilateral mastectomy rates. The age a woman first gives birth is also rising, meaning more patients will be faced with the decision to undergo this procedure before the completion of childbearing. Despite industry campaigns to present method of infant feeding as a “choice,” formula feeding is associated with increased illness and death for mothers and children alike. ¹ Adding to their wounds, women in the emotionally vulnerable perinatal time suffer grief and trauma related to the loss of breastfeeding.

Breasts have achieved a stamp of removal unlike any other organ in the body. Former smokers do not undergo preventative excision of both lungs, and melanoma is treated on an extremity without amputating all limbs. A “double testicle removal—just to be safe” would be considered outrageous. Even ovarian cancer, a far deadlier and more difficult to detect malignancy than breast cancer, often becomes a secondary concern in women of childbearing age who are at risk for developing this disease. It is clear to both physicians and patients that ovaries are necessary for creating a baby, but the breasts—a critical component of growing a healthy human from fertilized egg to childhood—are considered expendable.

Women electing to undergo a bilateral mastectomy in their childbearing years may not recognize the potential risks associated with their “choice.” Though the $55 billion per year formula industry wants us to believe otherwise, artificial milk feeding is associated with maternal development of cancer, depression, diabetes, and cardiovascular disease. ² Children have increased rates of ear infections, diarrhea, pneumonia, as well as elevated risks of obesity, diabetes, leukemia, and sudden infant death syndrome. ² Safety recalls and supply chain disruptions during the COVID pandemic further illuminate risks of human milk substitutes. Unadjusted for inflation, formula costs the economy $18.5 billion per year from missed work, medical costs, and pediatric death. ³

Surgical proponents of bilateral mastectomy argue that results can rival cosmetic breast augmentation, and they have financial incentives to promote this message. Even the layperson term “double mastectomy” suggests some sort of increased benefit to the recipient. Sadly, it is the opposite: a reconstructed breast provides contour in clothes, but is otherwise a permanently altered organ physically, emotionally, and sexually. ⁴ It is nonfunctional as a gland to feed and comfort human infants.

Patients may report that they “just wanted to be alive” and “didn't want the cancer to come back in the other breast.” In reality, a bilateral mastectomy does not provide a survival benefit to any women, even those carrying the BRCA gene mutation. ⁵ Patients have a far higher chance of developing metastatic disease elsewhere in their body ⁶ than presenting with a new breast cancer in the short-term future of their childbearing years: contralateral cancer risk is, on average, 0.1–0.5% per year. ⁷

Women are often unaware of the safety of recommendations for screening patients until they are ready to undergo preventative surgery. ⁸ Even if women do not plan to have children, potential risks nevertheless require exploration. Formula is utilized when medically necessary, but should not be considered an acceptable default as a result of suboptimal counseling and the heavy-handed wielding of a scalpel.

My hope is that we can reframe the mastectomy conversation so that patients and surgeons understand the significant consequences of removing normal breasts in young women. Rather than viewing the breasts as a dispensable, premalignant organ destined for excision, we should focus on supporting their role as the gland that defines our species. As physicians, we should guide patients in making informed decisions based on facts, not fear. We must expose unethical marketing in the formula industry, provide education on human lactation to health care providers, and remind surgeons of the oath that guides our life's work: First, do no harm.