In 2013, actress Angelina Jolie sparked a national conversation when she published an article in the New York Times describing her decision to have preventive double mastectomy, also called prophylactic breast removal.
She made this hard choice after learning she had a gene mutation called BRCA1, which gave her an 87 percent chance of getting breast cancer, for which she had a family history.
It’s a decision that many women face, especially as doctors are increasingly able to determine a woman’s risk by identifying gene mutations that predispose them to breast cancer. These include BRCA1 and BRCA2, which are the most well-known; P53, which has the highest risk; as well as CHEK2 and PALB2.
Prophylactic breast removal is definitely something to consider if you have one of these known gene mutations,” explained Veronica Jones, M.D., breast surgeon at City of Hope. “But some families have very high predisposition to breast cancer without any known gene mutation. For example, if you have five sisters and they all had breast cancer by age 40, you’d probably want to consider it as well.”
Of course, with high-profile cases like Jolie and others comes an increase in fear and worry among the general population about the possibility of developing cancer.
“As women hear more about this, it can be easy for them to overestimate their risk,” Jones said. “And if they think their risk is higher than it actually is, the thought of prophylactic removal can seem very appealing. That’s why we try to make sure our patients understand their real risk of cancer versus the risks of having prophylactic surgery, which can include complications like bleeding or infection.”
So how do women know if they should get prophylactic breast removal rather than regular screenings? Jones said the patients she sees are usually the ones at very high risk because they either have one of the known gene mutations or an overwhelming family history. That’s because these risk factors also increase the chance that the cancer that could be a more aggressive form that could develop and spread quickly in the time between regular screenings.
Fortunately, as the ability to diagnose a woman’s risk has improved, so has the quality of the surgeries available to them. At City of Hope, breast cancer surgeons work side by side with the plastic surgeons who perform the subsequent reconstruction. In many cases, the two procedures are done at the same time, called immediate reconstruction.
“We do a lot of immediate reconstructions, where we share space with the plastic surgeons, and they focus on reconstruction as we finish the mastectomy,” Jones said. “Not every patient is a candidate, but for those who are, it’s relatively easy.”
The most common type of mastectomy done at City of Hope today is the nipple-sparing mastectomy, which can be done both prophylactically and to remove cancerous tissue. The surgeon makes a small incision along the edge of the nipple and removes the inner tissue, leaving most or all of the outside tissue, called the envelope, intact. Then the reconstructive surgeon places implants and finishes the reconstruction.
This type of reconstruction has been so successful at City of Hope that many patients who develop cancer on one side will choose to have prophylactic breast removal done on the other breast, even if they don’t have a gene mutation that puts them at risk of reoccurrence in the other breast.
“The quality of the reconstruction plays a huge part in that decision,” Jones said. “Even though breast cancer doesn’t typically travel from one breast to the other, I think patients who make that choice are satisfied and it gives them peace of mind to not have to continue getting screening or worry about it anymore.”
Plastic surgeon Mark C. Tan, M.D., employs a pair of innovative microsurgeries that are showing great results in treating the symptoms of lymphedema, a common complication following breast (and other) cancer surgery.