Women with a family history of breast cancer who are diagnosed with breast cancer are often counseled to undergo prophylactic mastectomy as part of their treatment for breast cancer.The majority of such individuals make these decisions in haste and without appropriate genetic counseling or testing.Most of them when tested for BRCA or other established mutations find that they are not mutation carriers.In retrospect, this realization leads many to question the wisdom of their prophylactic surgery which is often associated with complications and quality of life problems which they never envisioned.We have designed an algorithm for management of these patients which minimizes these lifelong problems and selects those most likely to be at risk of genetic mutation for prophylactic surgery.