Because doctors must know the makeup of a particular mutation within a given family in order to do a test, they generally want to first test another family member who has cancer. While some families willingly march in to be tested en masse, others shatter over the issue and a majority decide not to be tested. There is extensive counseling for those who face the choice. Of those who do take the test, about a quarter turn out to be positive. And only about 20 percent of those have their breasts removed.
Some hospitals do no more than a handful of the surgeries a year.
Some schedule a date for a prophylactic mastectomy for a year from now. They do not have a lot of other options. Most have their ovaries removed, an outpatient procedure done by laparoscopy which reduces the risk of breast cancer by about 50 percent. There is tamoxifen, a drug which reduces the incidence of breast cancer by about 45 percent, but which is linked to uterine cancer and blood clots. Intensive screening is also an option.