Preventive mastectomy and breast reconstruction: The Angelina Jolie effect

MANILA, Philippines - October is Breast Cancer Awareness Month.  Its observance is aimed at providing relevant information to all Filipino women, especially the thousands, who each year develop breast cancer.  Today, the emotional and physical results are very different from what they were in the past.  Much more is now known about breast cancer and its management.  New treatments as well as improved reconstructive surgery mean that women who have breast cancer today have better choices than ever before.  And among the two hottest topics on breast cancer today are preventive mastectomy and breast reconstruction.

These two topics were given further impetus this year when Angelina Jolie underwent both procedures.  Last May, she stepped forward and announced in an op-ed letter to the New York Times that she had undergone bilateral preventive mastectomies after she found out that she carried a genetic mutation that increased her odds of developing breast cancer significantly.  In addition, she also underwent immediate breast reconstruction.

Preventive mastectomy

Preventive mastectomy (also called prophylactic or risk-reducing mastectomy) is the surgical removal of breast cancer in women who are at high risk of developing the disease.  Existing data suggest that preventive mastectomy may significantly reduce (by about 90 percent) the chance of developing breast cancer in moderate- and high-risk women.  It is important for a woman who is considering preventive mastectomy to talk with a doctor about her risk of developing breast cancer, the surgical procedure and its potential complications, and alternatives to surgery.  Many women who choose to have preventive mastectomy also decide to have breast reconstruction to restore the shape of the breast.

Preventive mastectomy involves one of two basic procedures:  total mastectomy and subcutaneous mastectomy.  In total mastectomy, the doctor removes the breast tissue and nipple. In a subcutaneous mastectomy, the doctor removes the breast tissue but leaves the nipple intact. Doctors most often recommend a total mastectomy because it removes more tissue than a subcutaneous mastectomy.  A total mastectomy provides the greatest protection against cancer developing in any remaining breast tissue.

Women who are at high risk of developing breast cancer may consider a preventive mastectomy as a way of decreasing their risk of this disease.  Some of the factors that increase a woman’s chance of developing breast cancer are:

• Previous breast cancer.  A woman who has had cancer in one breast is more likely to develop a new cancer in the opposite breast. Occasionally, such women may consider preventive mastectomy to decrease the chance of developing a new breast cancer.

• Family history of breast cancer. Preventive mastectomy may be an option for a woman whose mother, sister, or daughter has breast cancer, especially if they were diagnosed before age 50.  If multiple family members have breast or ovarian cancer, then a woman’s risk of breast cancer may even be higher.

• Breast cancer-causing gene alteration. A woman who tests positive for changes, or mutations, in certain genes that increase the risk of breast cancer (such as BRCA1 or BRCA2 gene) may consider preventive mastectomy.

• Lobular carcinoma in situ.  Preventive mastectomy is sometimes considered for a woman with lobular carcinoma in situ, a condition that increases the risk of developing breast cancer.

• Diffuse and indeterminate microcalcifications or dense breast.  Rarely, preventive mastectomy may be considered for a woman who has diffuse and indeterminate breast microcalcifications (tiny deposits of calcium in breast) or for a woman whose breast tissue is very dense.  Dense breast tissue is linked to an increased risk of breast cancer and also makes diagnosing breast abnormalities difficult.

• Radiation therapy.  A woman who had radiation therapy to the chest (including the breasts) before age 30 is at an increased risk of developing breast cancer throughout her life.

Angelina Jolie was reportedly BRCA1 positive and was informed that she had an 87-percent chance of getting breast cancer and a 50-percent chance of getting ovarian cancer.  In the US, about 36 percent of BRCA-mutation-positive women opt for preventive double mastectomies.  In France, the number is much lower,  whereas in Northern Europe, the rate is close to 100 percent.

It is important for a woman who is considering preventive mastectomy to talk with a doctor about her risk of developing breast cancer, the surgical procedure, and potential complications.  All women are different, so preventive mastectomy should be considered in the context of each woman’s unique risk factors and her level of concern.

Breast reconstruction

Many women who have a mastectomy, either for prevention or treatment, have the option of having more surgery to rebuild the shape of the removed breast.  As more and more women plan for life beyond cancer, they’re thinking about how they will feel and look in the years to come.  Most women who undergo breast reconstruction report improved psychological, social, and sexual well-being, as well as satisfaction with the restored appearance of their breasts.  Breast reconstruction is done by a plastic surgeon in coordination with your breast surgeon.

Breast reconstruction entails several decisions and usually requires two or more surgeries to ensure a correctly positioned and appropriately shaped breast.  It’s important to learn about your options, remain patient throughout the process, and keep your expectations realistic.

Breast reconstruction can be done using either breast implants or tissue taken from somewhere else in the body.  Breasts can be rebuilt using implants (saline or silicone) or autologous tissue (that is, tissue from elsewhere in the body).  Most breast reconstructions performed today are immediate reconstruction with implants, such as the surgery performed on Angelina Jolie.

Breast reconstruction can be either immediate or delayed.  With immediate reconstruction, a surgeon performs the first stage to rebuild the breast during the same operation as the mastectomy.  A method called skin-sparing mastectomy may be used to save enough breast skin to cover the reconstruction.  With delayed reconstruction, the surgeon performs the first stage to rebuild the breast after the chest has healed from the mastectomy and after the woman has completed adjuvant therapy.

A third option is immediate-delayed reconstruction.  With this method, a tissue expander is placed under the skin during the mastectomy to preserve space for an implant while the tissue that was removed is examined.  If the surgical team decides that the woman does not need radiation therapy, an implant can be placed where the tissue expander was without further delay.  However, if the woman will need radiation therapy after mastectomy, her breast reconstruction can be delayed until after radiation therapy is completed.

Implants can also be inserted underneath the skin and chest muscle that remain after mastectomy, usually as part of a two-stage procedure.  In the first stage, the surgeon places a tissue expander under the chest muscle.  The expander is slowly filled with saline during visits to the doctor after surgery.  In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant.  The chest tissue is usually ready for the implant six weeks to six months after mastectomy.  Expanders can be placed as part of either immediate or delayed reconstructions.  An optional third stage of breast reconstruction involves recreating a nipple on the reconstructed breast.

In autologous tissue reconstruction, a piece of tissue  containing skin, fat, blood vessels, and sometimes muscle is taken from elsewhere in the woman’s body and used to rebuild the breast.  This piece of tissue is called a flap.  Different sites in the body can provide flaps for breast reconstruction.  These are:

• TRAM flap.  Tissue, including muscle, that comes from the lower abdomen.  This is the most common type of tissue used in breast reconstruction (see figure).

• DIEP flap.  Tissue that comes from the abdomen as in a TRAM flap, but only contains skin and fat.

• Latissimus dorsi flap.  Tissue that comes from the middle and side of the back.

After the chest heals from reconstruction surgery and the woman has completed adjuvant therapy, the surgeon can reconstruct the nipple and areola.  Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple.  A few months after nipple reconstruction, the surgeon can recreate the areola.  This is usually done using tattoo ink.  Skin-sparing mastectomy that preserves a woman’s own nipple and areola (called nipple-sparing mastectomy) is performed by some surgeons on select women who are at low risk of cancer recurrence.  Studies have shown that breast reconstruction does not increase the chances of breast cancer coming back or make it harder to check for recurrence with mammography.

It is important to keep your expectations realistic.  Breast reconstruction offers many benefits, but it won’t make you look or feel exactly like you did before your mastectomy.  Still, most women who choose breast reconstruction report high levels of satisfaction, regardless of the techniques used.  Reconstruction has been shown to have positive effects on well-being, self-esteem, sexuality, body image, and concerns about cancer coming back.

So, how did Angelina Jolie feel about her preventive mastectomy and breast reconstruction? 

“On a personal note,” she wrote, “I do not feel any less of a woman.  I feel empowered that I made a strong choice that in no way diminishes my femininity.” 

A charming passage in her op-ed piece was her brief description of her breast reconstruction:  “The results can be beautiful,” she reassured, adding that her children can see the small scars but other than that, “everything else is just Mommy.”  With that, she made breast cancer less fearful in the hearts of many women around the world.