by Eunice J Minford MA FRCS Ed, Consultant Surgeon, N. Ireland
The world’s media was recently focussed on Angelina Jolie and her decision to have a prophylactic or preventative bilateral mastectomy to reduce her risk of developing breast cancer. Some celebrated her bravery and courage in being so open with her decision, and for taking the decision in the first place. Many felt it would help other women going through the same dilemma to see a leading world actress, renowned for her beauty and sexuality, undergo such a major operation. Others were critical of her decision, calling it ‘fearful’ rather than brave and that there were other options available.
I interviewed a breast surgeon who performs bilateral preventative mastectomy with immediate reconstruction to hear more on this controversial area:
Q: How many bilateral preventative mastectomies do you perform each year, and what are the indications?
A: I do about 1-2 prophylactic bilateral mastectomies with immediate reconstruction per year. It forms about 1-2% of my mastectomy workload.
The main indication is for women who are BRCA1 or BRCA 2 positive and who are deemed high risk for breast cancer as determined by a geneticist.
Q: Are there options available other than mastectomy for such patients?
A: Yes, they can undergo regular surveillance, which traditionally has been with annual mammograms but is now being superceded with MRI scans for these cases. There is also the possibility of using drugs like tamoxifen and other anti-hormonal agents which can significantly reduce the risk of developing breast cancer, but not as much as mastectomy.
There are a range of risks and different ways to stratify risks, but if the lifetime risk of a woman developing breast cancer in the general population is around 1 in 10, some of these women have a risk of 1 in 2, or higher. In some cases there can be up to a 90% chance they will develop breast cancer; drugs can reduce that by 30-40% and surgery reduces it by 80-90%.
Q: What are the implications for a woman undergoing prophylactic mastectomy and immediate reconstruction?
A: It is not a decision to be taken lightly by any means and there are many implications including physical, psychological and psychosexual. Ideally, we need a multi-disciplinary team with geneticist and counsellor/psychologist and the appropriate specialists who can assist these women with their decision, but it does not happen universally due to lack of funding.
There are different types of reconstruction and there can be significant complications and women need to be prepared for that. We spend a lot of time with women explaining that to them. Reconstruction can be performed using implants or using the patient’s own tissues e.g. from the abdominal wall in what is called a TRAM flap. Implant surgery is more straightforward than TRAM flap surgery. Not everyone can have a TRAM flap, e.g. smokers and those with co-morbidities and previous abdominal surgery. The advantages of a TRAM flap are that it is the body’s own tissue, has a more natural feel, it changes as the body changes and has a good cosmetic appearance. However, it does weaken the abdominal wall and there can be significant complications with partial (or rarely complete) flap necrosis and chronic wound problems. It can take 6 months before a woman feels back to normal after such surgery. She needs to be aware of all of that.
It is a very big decision and if there is any doubt then it is better to back off and give it further consideration. It’s fine when all goes well but it can be very traumatic when they get a complication.
Q: Some have suggested that with new information coming to light in the field of epigenetics, that shows how our environment influences genetic expression, switching genes on and off, that perhaps by making lifestyle changes that alter the environment beneficially then perhaps these genes may not get ‘switched on/off’ that result in cancer, and mastectomy could be avoided?
A: Perhaps one day we will have a more complete picture of what does and doesn’t turn these genes on and off, but it is still an early science and we don’t have those answers at present. For now, you have an individual with a gene that carries significant risk and there are potential consequences for that individual and we cannot yet say to them, ‘do this or do that’ and you will definitely avoid breast cancer.
Q: Would you recommend women looking at other areas of their life in terms of reducing their risk for breast cancer and also to aid their recovery post-operatively?
A: Definitely, it is common sense that we need to look at stress, exhaustion, diet, lifestyle etc. I have noticed that women who take care of themselves with diet and fitness etc seem to recover more quickly from surgery, even ahead of schedule.
Going through such a major procedure can provide an opportunity for people to stop and take stock of their lifestyle. Of course some people don’t want to change their lifestyle and even when we do want to, we can struggle with it. As doctors, we advise people to do it, but are we doing it ourselves? Ultimately, we all need to take responsibility for our own wellbeing.