In 2013, actress Angelina Jolie underwent a bilateral prophylactic mastectomy to reduce her risk of developing breast cancer. She didn’t have cancer, but a blood test showed that she inherited a genetic defect in the BRCA gene that put her lifetime chance of developing breast cancer upwards of 80 percent.
Her decision was viewed as brave and courageous and started to re-shape the way women felt about their breasts when it comes to breast cancer prevention and treatment. This change in attitude has been dubbed the “Angelina Jolie Effect.”
This topic was in the news again in July 2015, when the Wall Street Journal published an article headlined, “The Double Mastectomy Rebellion: Defying Doctors, More Women with Breast Cancer Choose Double Mastectomies.”
This piece illustrated the increasing national trend toward mastectomy and contralateral prophylactic mastectomy, which entails removing the breast with cancer as well as the unaffected breast.
Those of us that specialize in the treatment of breast cancer have known for decades that removing “healthy” breast tissue does not offer any survival advantage in patients with breast cancer. You see, breast cancer kills women because of metastasis to other areas of the body such as the lungs, liver, bones and brain.
Considering the breast that has cancer, breast conservation (lumpectomy with radiotherapy) has been shown in multiple large clinical trials to achieve survival rates that are exactly the same as mastectomy. Taking more of the same breast is not better.
Since breast cancer does not spread to the non-affected breast, removing it would make sense only if it offered a survival advantage by preventing a new breast cancer from occurring. It doesn’t.
That is because new cancers in the opposite breast are not as common as patients think and, if they do occur, they are usually treated with a high success rate. So if survival is the goal, nothing is achieved with bilateral mastectomy.
As a breast surgical oncologist, unless the patient had an inherited predisposition to breast cancer, I previously spent a tremendous amount of time talking newly diagnosed breast cancer patients out of mastectomy and particularly out of removing the other, healthy breast.
Historically, it was not uncommon for a breast surgeon to report a breast conservation rate of 60 to 75 percent and a contralateral prophylactic mastectomy rate of less than 2 percent. Ten years ago, patients were told that there was no survival advantage to removing the unaffected breast, and there was no further discussion. Breast conservation rates were on the upsurge at that time.
But in recent years, attitudes have changed, and the rate of bilateral mastectomy has risen. This transformation was not due to new scientific data.
For whatever reason, patients started giving reasons for requesting bilateral mastectomy that were unrelated to survival. These were related to quality of life, fear and emotional well-being. Here are some examples.
- Fear of further breast imaging and biopsies. By the time a patient is diagnosed with breast cancer, they have been on an emotional roller coaster. Multiple trips to the imaging center, multiple mammograms and ultrasounds, needle biopsies, waiting for results, MRIs, … these are stressful events, and most patients will do anything not to go through it again, even if the diagnosis is benign. Paradoxically, in our efforts to find breast cancer earlier, we have created a deterrent.
- Fear of more treatment if they develop a new cancer in the other breast. Treatment regimens have improved, but they remain lengthy and challenging. Once is enough for most patients.
- Reconstruction. In the patient requiring a mastectomy for cancer, reconstruction is commonly performed at the same time. Breast reconstruction has improved dramatically, and a reconstructed breast can look very realistic, but often there are issues with symmetry with the other breast. Women like to be symmetric, so a bilateral mastectomy with reconstruction makes sense in this regard.
- “I’ve done everything” and “More is better.” Patients like to feel that they have done everything in their power to battle this disease, even if statistically this additional surgery offers no survival benefit. They feel better about themselves, which might have some positive impact on their emotional well-being.
So now when we counsel a patient, the dialogue is much different. Make no mistake: Patients must first understand that they are not going to live longer by removing unaffected breast tissue in the same or opposite breast. They also need to know that reconstructed breasts are not always perfect and can be cosmetically inferior to their own breasts.
Once this is understood, the conversation doesn’t end. It goes to the next level where the patient has input into the decision-making process.
Surgeons are not performing surgery that is un-indicated and patients are not blatantly defying their surgeons when it comes to the choice of a bilateral mastectomy.
Medicine is becoming more patient-centric with individualized approaches to care. Clinicians are becoming more sensitive to patient quality-of-life issues, and most of my colleagues are now willing to spend significant amounts of time educating their patients to help them arrive at a treatment plan that is acceptable to both parties, whether it is a lumpectomy, mastectomy, or bilateral mastectomy.
William E. Burak Jr., M.D., FACS is a breast surgeon and director of Breast Oncology at the Curtis and Elizabeth Anderson Cancer Institute at Memorial University Medical Center in Savannah.