Risk-reducing mastectomy for high-risk breast cancer patients

Patients at high risk of developing breast cancer often face the complex and deeply personal decision of whether to undergo risk-reducing (prophylactic) mastectomy. At Penn Medicine, breast cancer specialists support patients every step of the way, from risk education to thorough surgical planning, state-of-the-art surgical methods, comprehensive post-surgical care, and mental health support.

Management begins with a comprehensive risk assessment incorporating genetic findings, family history, and personal risk factors. For many patients, a personalized surveillance plan is appropriate; for those with more significant risk, prophylactic mastectomy may offer significant long-term benefits.

Penn Medicine’s high-risk breast program, delivered by a multidisciplinary team that includes advanced practice providers with physician oversight, offers personalized risk assessment and coordinated access to genetic counseling to support shared decision making. This approach ensures patients fully understand their individual risk and the implications of each management pathway.

When risk-reducing mastectomy is indicated, patients have access to advanced surgical techniques and coordinated breast reconstruction options within a high-volume program. This integrated model, encompassing risk evaluation, longitudinal screening, surgical management, and survivorship, supports evidence-based, preference-aligned care for high-risk patients.

“I’ve seen different [care] models, and I believe Penn Medicine has a very patient-centered approach to care,” says Ashley Newman, MD, a breast surgeon at Penn Medicine Princeton Medical Center. “Everybody, from the first person the patient meets at registration to the last nurse that discharges them from the recovery room—every single person really wants that patient to be successful and takes extra steps to make sure of it.”

Patients making a preventative decision

High-risk breast cancer patients who consider risk-reducing mastectomy generally fall into one of two categories: individuals with confirmed genetic mutations and those without an identifiable germline mutation but with elevated risk, including people with a strong family history or those experiencing screening fatigue after years of intensive surveillance.

Patients with a BRCA mutation who elect to undergo risk-reducing mastectomy have about a 90 to 95 percent reduction in breast cancer risk. However, the procedure is not limited to patients with known BRCA mutations.

“I’ve also had patients undergo risk-reducing mastectomy who had no gene mutation but had a very, very strong family history of breast cancer,” says Dr. Newman. “These patients usually come to that decision after a few years of screening and false positive imaging results that have required multiple biopsies.”

Supporting the decision

The decision to undergo risk-reducing mastectomy is not straightforward, even for those with significantly elevated breast cancer risk. Many high-risk patients defer risk-reducing surgery and instead rely on a modern, individualized active surveillance plan, reflecting the expanding range of effective screening options. This may include alternating mammography and MRI, with ultrasound used selectively based on breast density and additional risk factors.

“We have much more effective methods of screening now. There is also new technology becoming available, which will offer patients more options for screening. One of the most exciting advances is the Clairity breast AI tool developed by Dr. Constance Lehman at Harvard. This tool can provide a five-year risk assessment for breast cancer based on a patient’s mammogram,” says Dr. Newman.

The decision to proceed with screening versus surgical risk reduction, Dr. Newman notes, very much depends on the patient’s goal and feelings about cancer risk. Penn Medicine breast surgeons guide patients who choose risk-reducing surgery through the decision-making process, explaining complication risks, setting realistic expectations, and quality of life considerations, including potential after-effects. “After a mastectomy, we expect the chest wall or the reconstructed breast to be permanently numb,” says Dr. Newman. “I set that expectation at the start because I think that’s a very important piece that, if you’re not prepared for, can really affect your well-being after surgery.”

Optimizing surgical planning

Meticulous preoperative planning is critical to achieving optimal outcomes in prophylactic mastectomy. “With patients who are high risk, things can change in six-month periods,” says Dr. Newman. “I prefer to have some recent imaging within three months before surgery.”

Timing imaging close to surgery reduces the risk of intraoperative surprises. If an occult cancer is found behind the nipple, the surgical approach changes entirely; a nipple-sparing approach becomes inappropriate and staging the axilla becomes necessary. Discovering this only after a dated preoperative scan creates significant downstream problems.

Conversely, patients whose imaging is clear do not require lymph node assessment. “This significantly reduces postoperative morbidity,” says Dr. Newman, including the risk of lymphedema and arm tightness and pain that can occur when only a single lymph node is removed.

Advanced surgical procedures

Patients who choose prophylactic mastectomy at Penn Medicine are cared for by surgical oncologists with expertise in advanced techniques, including nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM), as well as aesthetic flat closure for patients who choose not to have reconstruction. “It’s always a very delicate balance in the operating room of trying to remove as much breast tissue as possible, and also not completely devascularizing the skin or nipple,” says Dr. Newman.

To advance these surgical methods, Penn Medicine breast surgeon Ari Brooks, MD, has participated in a multi-center study testing the safety and efficacy of robotic-assisted risk-reducing NSM since 2019. This minimally invasive technique is designed to remove as much tissue as possible through smaller incisions, improving cosmetic outcomes while reducing devascularization risk. The FDA granted 510(k) clearance for use of the da Vinci SP Surgical System in nipple-sparing mastectomy procedures in December 2025, and Penn Medicine continues to contribute to the growing body of evidence evaluating this approach.

Dr. Brooks is currently evaluating patients for robotic NSM, and reports that patients are very happy with the aesthetic outcomes of robotic mastectomy. In addition, he says, patients feel that recovery is better, with less pain and fewer complications by comparison to open nipple-sparing procedures. More information about robotic NSM and the associated study is available at the Penn Medicine Clinical Briefings.

For patients who choose reconstruction following prophylactic mastectomy, Penn Medicine’s RESTORE Center for Advanced Breast Reconstruction (the world’s highest-volume center for breast microsurgery) offers the full spectrum of reconstructive options. Most patients undergoing mastectomy with reconstruction have a tissue expander placed at the time of surgery. The expander is gradually inflated during the healing period and exchanged for a permanent implant or flap reconstruction three to six months later, allowing the care team to optimize the final result.

These reconstructive options are fully integrated into Penn Medicine’s multidisciplinary surgical approach, ensuring patients have coordinated access to surgical oncology and reconstructive expertise throughout their care.

Supportive care after mastectomy

Penn Medicine provides support for patients following risk-reducing mastectomy, to address their physical recovery and ongoing care needs.

Surgical oncology is closely coordinated with medical and radiation oncology, ensuring that if an occult malignancy is identified at the time of surgery, patients can be seamlessly transitioned to appropriate oncologic care.

Postoperative rehabilitation is also a key component of recovery. Patients are routinely referred to physical therapy following surgery, particularly if a lymph node evaluation is performed. For those undergoing axillary assessment, physical therapy includes lymphedema screening and prevention strategies to reduce the risk of long-term morbidity.

Referring a patient to Penn Medicine

Patients are referred to breast surgeons through several pathways. Within the Penn Medicine system, specialists at the MAPS (Management, Assessment, Prevention, and Surveillance) Clinic for Breast Health provide evidence-based monitoring, risk assessments, personalized preventive care strategies, and genetic screenings.

Patients with an identified mutation can access genetic counseling at the Basser Center for BRCA, the first comprehensive center for the research, treatment, and prevention of BRCA-related cancer. These programs play a key role in identifying and guiding high-risk patients, connecting them with surgical oncologists when prophylactic mastectomy becomes part of the care discussion.

Referrals and consultations

Providers can refer patients to Penn Medicine by calling 877-937-7366 or through the online referral form. An email confirmation will be sent to the referring provider once the patient’s appointments are scheduled.