Cutting a Fine Line


By Jess Goulart

Photo courtesy of williami5.

Perhaps Angelina Jolie’s decision inspired them. Perhaps the recent discovery of genes that more accurately predict a future fight with breast cancer terrified them. Perhaps the “culture” of breast cancer really did make them feel obligated to take more aggressive moves toward fighting it, as Dr. Barron H. Lerner, author of The Breast Cancer Wars, told The New York Times.

Whatever the reason, researchers estimate that the number of bilateral mastectomies (the surgical removal of both breasts) after being diagnosed with breast cancer has increased by nearly 14 percent annually since 1998 in women under 40 years old.

For those unfamiliar, the available treatment options for women with breast cancer are hormone therapy, a lumpectomy (a breast retaining surgery that removes only the growth) plus radiation therapy, or a mastectomy–which includes various options like segmental and radical mastectomy. Women who have had the cancer may undergo genetic testing for two genes that indicate they are likely to experience a recurrence–BRCA1 and BRCA2.

Brigid Killelea, Assistant Professor of Surgery (Oncology) at the Yale School of Medicine, tells BTR that there are two populations of women who have been diagnosed with breast cancer and are considering a mastectomy. The first is patients who have been diagnosed and present with the BRCA genes, or have a family history.

“For those patients, doing a bilateral mastectomy really is a reasonable choice, because they’re at a much higher risk for getting another breast cancer, in the future, on the other side,” she explains.

The other population is women who have no family history and do not have the BRCA gene; for them, Killelea says the surgery doesn’t really affect their mortality, as they are actually more at risk for having a recurrence on the same side.

A study published in the Journal of the American Medical Association supports her assertion. It found that, for women already diagnosed with breast cancer, there was no difference in survival rate between the two treatments.

But it’s not just diagnosed patients who consider the surgery. In 2012, a 24-year-old Miss America contestant said she would be pursuing a double mastectomy after the contest because of her family history with the disease. This kind of preemptive surgery is called a prophylactic mastectomy.

It’s a hot button word in the media, and studies show a double mastectomy cuts death rates in half–not necessarily prophylactic mastectomy–but the number of women opting for the procedure remains steadily low. Perhaps this is because a woman can only get genetically tested for the BRCA gene if she is deemed high risk.

“For most of those patients we try to council them and their family members because it’s important to try and get any living relatives who’ve had breast cancer to have genetic testing,” says Killelea, “that way if a gene is identified in that family member, then subsequent generations can undergo testing. And if they don’t have that mutation then really they are at average risk.”

Some might wonder, why the caution? A woman’s body is her own and she should be allowed to choose what to do with it. If she wants a preventative surgery, why stop her?

Well, like any surgery, mastectomies carry risks. For anyone who doesn’t understand the intricacies of such an operation, Emma Keller gave a moving, detailed first-hand account in The Guardian. In it, she described how her mastectomy required three doctors in total; the fear; the pain; and how during the procedure “the veins and arteries from my stomach had to be reconnected to those in my breasts so that the flesh would live.”

Keller ended her article asking when another option will exist, because though she ended up cancer free the process was horrific for her.

As Keller proves, a prophylactic mastectomy is difficult on both body and mind, and Killelea says the decision tree in these circumstances is extensive. It’s a fine line between when the surgery is worth it and when another option is just as good and less risky.

If you think you’re at risk, remember that the guidelines in the United States are to start screening at age 40. For patients with a strong family history, Killelea recommends a screening immediately after a woman is done child birthing or 10 years before the age of diagnosis for the family member who had breast cancer.