As appeared in Huffington Post

Among the most controversial decisions in surgery today may well be whether patients should request and doctors should (or not) perform mastectomy on the healthy breast. Today’s top international breast surgeons do agree on several things: Patients must consult the geneticist, the oncologist and a psychologist before reaching the decision.

There are important trends that bode well for a proactive choice: Most surgeries today include both mastectomy and simultaneous reconstruction. Further, breast surgeons are performing plastic surgery with the intention of faster healing or collaborating with plastic surgeons soon after the operation for reconstruction.

New technologies supporting the decision are also changing the game. Acellular dermal matrix (ADM) or use of porcine animal skin and other biologics is one way to close the breast generally.

New matrix surgical mesh, which provides the scaffolding and can resorb into the body — then disappear — also reassures women that a foreign substance will not remain (other than the implant itself). Tissue regeneration will replace the mesh and give the breast the support to heal. Novus Scientific, which has a patent on this technology for two-stage resorption in layers, has set-out to give both doctors and patient more options.

Breast surgeons are now experimenting with ADM, other biologics and synthetics. Patients should know more about the expense of ADM, the new technologies and why resorption is so important.

Risk Reducing Mastectomy — Genetic Markers and Prevention

I spoke with leading breast surgeons in London last week about risk-reducing BRCA 1 surgery at the Royal College of Physicians www.londonbreastmeeting.com.

There is some consensus. First, that Angelina Jolie was truly heroic in making her self-disclosure last year and increased awareness.

Second, that the protocol for selection may be changing; doctors are just not comfortable recommending preventative surgery with only the initial genetic marker as guidance.

Angelina Jolie’s courageous decision to go public with her choice sent inquiries skyrocketing worldwide to doctors’ offices — at one U.K. hospital women’s questions increased 500 percent. In the Times last April, she discussed her reasons:

“The truth is I carry a faulty gene, BRCA1, which sharply increases my risk of developing breast cancer and ovarian cancer,” Jolie disclosed. “My doctors estimated that I had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer, although the risk is different in the case of each woman.”

“Only a fraction of breast cancers result from an inherited gene mutation.” she said. “Those with a defect in BRCA1 have a 65 percent risk of getting it, on average.” See full NYT opinion piece she wrote: http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html?_r=0

Here is what world-renowned breast surgeons have to say as guidance for women:

Dr. Paolo Montemurro of Sweden: “It is a very controversial procedure. First, from a genetics view, it is very expensive to do such an investigation to see if there is any genetic predisposition in this kind of disease. If I had a patient come to me and asking me to do a preventative mastectomy and replace the breast with implants I would need to take many factors into consideration. I would probably refer the patient a psychologist first before operating. I would also consider the age, has she had kids already or is she planning to have kids — so it is multi-factorial situation.”

Dr. Maurizio Nava of Italy said: “So women are receiving information that is not completely true and so we have to go in with the patient and explain that only selective patients with particular mutations must be treated in this way. So if you have a genetic mutation in a patient this means there is a higher risk of having breast cancer in respect to the rest of the population. But that is a small percentage of patients, nowadays we are talking about 15-20 percent or more. That doesn’t mean that if Angelina Jolie did it for a real reason, anyone should. She had a mutation, so she needed to be treated in this way. Let’s take a logical approach, then we can decide it together.”

Dr. Riccardo Bonomi also of Italy said: “It has been remarkable, the fact that Angelina Jolie made the decision to have her bi-lateral mastectomy. We have seen an increase in referrals to the geneticists in order to establish if there is any high risk for a lady developing breast cancer. We have gotten an increase of ladies asking for bi-lateral mastectomy. In view of the constraint from the money point of view, we are actually not allowed to perform risk-reducing mastectomies on patients that do not have the BRCA 1 or 2 genetic mutation; but for sure we have increased the number of bi-lateral mastectomy.”

Dr. Anushka Chaudhry of the U.K. said: “In my field, I have always had women requesting prophylactic mastectomies either due to being gene carriers or because of high risk of family history. Since Angelina Jolie has come out and been a real advocate for women, I think what she did was amazing because she is someone who is very much in the limelight. It has massively increased our referrals of patients. A lot of the referrals we get aren’t necessarily adequate referrals, they are sometimes just people who have a really high sense of risk for themselves.”

“I think the real role of a breast surgeon is to be a proper advocate for that patients. So as much as we appreciate the anxiety that they have to live with every day, those that are BRCA 1 positive or those with a family history we really have to stress the potential psychological and physical outcomes they might have after having a prophylactic mastectomy with or without reconstruction. We make sure we are checking the necessary boxes to insure the patient is really ready to go down that path. Most of these women are very young, they have families and they are worried about the future.”

“So I personally insist my patients have psychological counseling. They all have to undergo genetic testing and in fact there are a lot of people who will be refused genetic testing because their family history isn’t strong enough; but still they really want to undergo the surgery. And again, being the advocate for them, I would discuss it with those patients in a multidisciplinary setting with the rest of my colleagues if this patient should really undergo that kind of treatment. I think showing them a lot of pre- and post-op photographs really has to give them a realistic expectation of what can happen after this kind of surgery and most importantly the complications side of things is where there can really be a real shortfall. Nothing is really smooth sailing and I think the more people know that something can go wrong with what essentially is surgery where there is no cancer.”

Breast cancer alone kills some 458,000 people each year, according to the World Health Organization, mainly in low- and middle-income countries.

It should become a priority to ensure that more women can access to gene testing and lifesaving preventive treatment. The cost of testing for BRCA 1 and BRCA 2, at more than $3,000 in the United States, remains an obstacle for many women.