Preventative Bilateral Mastectomy with Immediate Reconstruction

by Eunice J Minford MA FRCS Ed, Consultant Surgeon, N. Ireland

The world’s media was recently focussed on Angelina Jolie and her decision to have a prophylactic or preventative bilateral mastectomy to reduce her risk of developing breast cancer.  Some celebrated her bravery and courage in being so open with her decision, and for taking the decision in the first place. Many felt it would help other women going through the same dilemma to see a leading world actress, renowned for her beauty and sexuality, undergo such a major operation. Others were critical of her decision, calling it ‘fearful’ rather than brave and that there were other options available.

I interviewed a breast surgeon who performs bilateral preventative mastectomy with immediate reconstruction to hear more on this controversial area:

Q: How many bilateral preventative mastectomies do you perform each year, and what are the indications?

A: I do about 1-2 prophylactic bilateral mastectomies with immediate reconstruction per year. It forms about 1-2% of my mastectomy workload.

The main indication is for women who are BRCA1 or BRCA 2 positive and who are deemed high risk for breast cancer as determined by a geneticist.

Q: Are there options available other than mastectomy for such patients?

A: Yes, they can undergo regular surveillance, which traditionally has been with annual mammograms but is now being superceded with MRI scans for these cases. There is also the possibility of using drugs like tamoxifen and other anti-hormonal agents which can significantly reduce the risk of developing breast cancer, but not as much as mastectomy.

There are a range of risks and different ways to stratify risks, but if the lifetime risk of a woman developing breast cancer in the general population is around 1 in 10, some of these women have a risk of 1 in 2, or higher.  In some cases there can be up to a 90% chance they will develop breast cancer; drugs can reduce that by 30-40% and surgery reduces it by 80-90%.

Q: What are the implications for a woman undergoing prophylactic mastectomy and immediate reconstruction?

A: It is not a decision to be taken lightly by any means and there are many implications including physical, psychological and psychosexual. Ideally, we need a multi-disciplinary team with geneticist and counsellor/psychologist and the appropriate specialists who can assist these women with their decision, but it does not happen universally due to lack of funding.

There are different types of reconstruction and there can be significant complications and women need to be prepared for that. We spend a lot of time with women explaining that to them. Reconstruction can be performed using implants or using the patient’s own tissues e.g. from the abdominal wall in what is called a TRAM flap. Implant surgery is more straightforward than TRAM flap surgery. Not everyone can have a TRAM flap, e.g. smokers and those with co-morbidities and previous abdominal surgery. The advantages of a TRAM flap are that it is the body’s own tissue, has a more natural feel, it changes as the body changes and has a good cosmetic appearance. However, it does weaken the abdominal wall and there can be significant complications with partial (or rarely complete) flap necrosis and chronic wound problems. It can take 6 months before a woman feels back to normal after such surgery. She needs to be aware of all of that.

It is a very big decision and if there is any doubt then it is better to back off and give it further consideration. It’s fine when all goes well but it can be very traumatic when they get a complication.

Q: Some have suggested that with new information coming to light in the field of epigenetics, that shows how our environment influences genetic expression, switching genes on and off, that perhaps by making lifestyle changes that alter the environment beneficially then perhaps these genes may not get ‘switched on/off’ that result in cancer, and mastectomy could be avoided?

A: Perhaps one day we will have a more complete picture of what does and doesn’t turn these genes on and off, but it is still an early science and we don’t have those answers at present. For now, you have an individual with a gene that carries significant risk and there are potential consequences for that individual and we cannot yet say to them, ‘do this or do that’ and you will definitely avoid breast cancer.

Q: Would you recommend women looking at other areas of their life in terms of reducing their risk for breast cancer and also to aid their recovery post-operatively?

A: Definitely, it is common sense that we need to look at stress, exhaustion, diet, lifestyle etc. I have noticed that women who take care of themselves with diet and fitness etc seem to recover more quickly from surgery, even ahead of schedule.

Going through such a major procedure can provide an opportunity for people to stop and take stock of their lifestyle. Of course some people don’t want to change their lifestyle and even when we do want to, we can struggle with it. As doctors, we advise people to do it, but are we doing it ourselves? Ultimately, we all need to take responsibility for our own wellbeing.

87 thoughts on “Preventative Bilateral Mastectomy with Immediate Reconstruction

  1. How great would it be to interview women who have had mastectomies and hear from them what their experience has been – it is about learning and being fully informed and knowing what has worked and what has not worked, and knowing that there is no one answer fits all response, but that rather it is about each of us working out what is best suited for our situation – learning from others is a very valuable resource.

  2. It is clear to me from this interview that as women we all hold the choices to ‘love ourselves up’ in other words look after ourselves more and that this is indeed a wonderful beginning to health and vitality.

  3. Amazing Eunice – I love the impulse you had to interview this breast surgeon and it has been super informative to here what she had to share! Thank you!

  4. Taking responsibility for our own wellbeing is essential and, faced with a decision on serious surgery, is essential for all the medical staff involved in the procedure.

  5. Thank you for this informative interview which clearly explains the options but also that this operation is not something to be taken lightly and that how we care for ourselves plays a big part in how well we recover from any surgical intervention. This is empowering as it shows that rather than being a victim of e.g. cancer we can choose to make changes if we are prepared to take responsibility for our past choices and make the necessary adjustments in our diet, lifestyle etc.

  6. It is not so much about living to avoid cancer but more about living the fullness of who you are so that cancer is not even a possibility.

  7. Thank you Eunice, it is great to know everything about this so when it would happen to us we know what are the options, implications and so on so that we can feel into it for ourselves what is right for us.

  8. We all need to take responsibility for the way we live and the choices we make, and so be responsible for our own wellbeing.

    1. Yes and if we did this the health service would have more resources to support those who have to go through operations such as the one described above which clearly need to be well supported to get the best outcome and which is not always the case now with over-stretched facilities becoming more and more the norm all over the country.

  9. Absolutely how we live affects our well-being, ‘Would you recommend women looking at other areas of their life in terms of reducing their risk for breast cancer and also to aid their recovery post-operatively?
    A: Definitely, it is common sense that we need to look at stress, exhaustion, diet, lifestyle etc’.

  10. When women are faced with surgical operations that can be life changing, I feel it is really important that the doctors offer unbiased information that will support and allow the patient to decide what is true for them. When we have clarity and understanding it is much easier to make these difficult decisions.

    1. I agree Alison it is important to have unbiased advise from people that truly care and know your situation.

  11. ‘We all need to take responsibility for our own wellbeing.’ To me this seems a no-brainer, but I have seen so many people who have surgery and return to their old ways of living without any idea or concern that their lifestyle may have been a contributing factor to their own disease process.

    1. Old habits can sometimes die hard, as they say. Sometimes our momentums of past choices are so strong it can seem almost impossible to change them, however, when one truly connects to the purpose of looking deeply after oneself, then there is no denial of the gold that lies within us all and how worth it it is to make a change that supports us.

  12. Thank you Eunice for a very informative article … these are the discussions we need to consider and have as women, to look at all our options and how we live, and make the decision to best support us, for as you say ‘Ultimately, we all need to take responsibility for our own wellbeing.’

  13. Insightful interview – great to have more awareness all-around before and what is preventable. I agree with if there is any doubt or something does not feel right it should be considered –everything is explored to honour the feeling within. The medical system provides a great support. We need to support ourselves and know our power within through what we know is right or true for our body and not give our power away to any / the system. If we use the system we are now apart of it.

  14. As we are yet to understand what turns these genes on and off, we are left with what we do understand and feel. That is it does make a difference when we care for ourselves and bodies in our daily choices.

  15. This is such an informative article that I would recommend every woman to read. It is an interviewed with a breast surgeon who performs bilateral preventative mastectomy with immediate reconstruction. It is great to hear more from an expert in this area. And it is great to hear the closing line from this interview coming from a surgeon . . . “Ultimately, we all need to take responsibility for our own wellbeing.” . . . as everything keeps coming back to this true.

  16. This is a very interesting interview, Eunice. Thank you. It is almost surprising how few such operations he does.

  17. Taking responsibility for our own lifestyle choices and wellbeing is preventative medicine – and it doesn’t cost the overwhelmed health service anything.

  18. Thank you Eunice its great ti hear the voice of the surgeon doctor in issues like this. Its amazing to consider all the evidence and work thats done re epigenetic and its still not enough ” still an early science and we don’t have those answers at present. ” .

  19. Yes we all need to take responsibility for our own wellbeing and then review whether, for example, an operation is still required. Pertinent for me currently as I have put a minor operation on hold for 6 months to see if it is still necessary then after committing to a deeper level of self-care.

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