Removing both breasts to prevent cancer ... does it really make sense?

 Jennifer Mamby-Alexander, Contributor

When I was diagnosed with breast cancer, my initial choice to have a mastectomy and reconstructive surgery of the affected breast was difficult but necessary.

My final choice to have a skin-sparing mastectomy with reconstruction on the unaffected breast was not as difficult, because the initial surgery left me a bit lop-sided, and this second surgery helped to align and balance both breasts.

However, I have always been cognisant of the fact that the rind of breast tissue remaining after the skin-sparing mastectomy is still at risk for the development of cancer, so I do surveillance tests annually.

With all that said, would I have done preventative double mastectomy with reconstructive surgery before I was diagnosed with cancer and knowing I had a high risk of getting it? Not on your life.

The emotional turmoil, agony and stress that gripped me when I finally agreed to have a mastectomy after my cancer diagnosis made me realise that I could never have agreed to remove my normal breasts before such a diagnosis was made.

But several women have done it because they feel they had no choice. The issue has now become a major talking point with Hollywood actress Angelina Jolie's revelation of her bilateral mastectomy of her normal breasts to reduce her chances of developing breast cancer because she was found to have a mutant BRCA gene and her mother had died from ovarian cancer.

Normally, the BRCA gene helps to control regular cell growth but when specific mutations occur in these genes they can determine a higher risk for breast and ovarian cancer in women and also a higher risk for breast, prostate, pancreatic and, possibly, testicular cancer when found in men.

WOULD A MAN CUT OFF HIS TESTICLES?

Currently, a man without a diagnosis of cancer but with a strong family history of any of these cancers is still only offered the choice of vigilant surveillance and lifestyle changes with absolutely no suggestion to remove normal prostate glands, testes, pancreases or breasts to prevent or reduce the risk for developing cancer. If this procedure that is offered to women is of real benefit to their future health, why isn't it then offered to men and if offered to men, which man would agree to comply?

Jolie's choice has been met with a lot of controversy. In fact, she has been harshly criticised by Mike Adams in a Natural News article suggesting that she was "duped by her doctors into self mutilation for cancer she never had".

Women like Jolie, who have BRCA1 or BRCA2 gene changes, have about a 35 per cent to 84 per cent chance of developing breast cancer and between a 20 per cent and 40 per cent chance of developing ovarian cancer during their lifetime. These numbers show a wide range of chance and depend also on other personal and family history.

It is true that these cancers may be more difficult to treat but only about eight per cent of breast and ovarian cancers are linked to the BRCA gene changes. This means that the risks for developing breast cancer that is not linked to the genetic changes and family history, occur in more than 85 per cent of the cases and yet the normal 'at risk' population is not given advice about removing normal breasts as preventative measures.

In Jolie's case, she had a skin-sparing procedure that still leaves the nipple behind, a rind of breast tissue under the skin, and breast tissue in the arm pit that are potentially at risk for the development of breast cancer in the future.

I recently diagnosed a nodule of breast cancer just below the skin and lying adjacent to the prosthesis in a woman who had bilateral mastectomies to prevent recurrent cancer, so the hope of preventing breast cancer is never cured by bilateral mastectomies in the presence or absence of the disease.

Jolie must also realise that removal of both breasts has absolutely no effect on her future risk for not getting ovarian cancer, as both ovaries are still in place. Conversely, if she was offered a single choice of surgery, total removal of both ovaries prevents any development of ovarian cancer in the future and significantly reduces the risk of the development of hormone-dependent breast cancer as well.

That may have been a better choice for her, and to reduce her future chances for getting breast and ovarian cancer to near zero. The drastic measures of removing both ovaries, both breasts and taking anti-oestrogen medications for life would have been the best option. Her removed ovaries could have been stored frozen if she desired to have children in the future.

LIFESTYLE CHOICES

Okinawa in Japan has the largest percentage of centenarians in the world with the lowest frequency of cancers, strokes, heart disease and dementia. They accomplish this by adopting healthy lifestyles; remaining physically active even when ageing, and having a relaxed approach to life.

The presence of a BRCA1 or BRCA2 gene does not test for cancer itself but gives persons at risk the chance to make informed medical and lifestyle decisions. It should be used to help women and men who have a strong family history of breast and ovarian cancers find out if their chance is high enough to think about preventative measures before cancer develops.

These measures should first include doing more frequent vigilant screening tests such as clinical breast examinations, mammograms, ultrasounds, biopsies, breast-specific gamma imaging and starting them at an earlier age, as well as adopting a healthy lifestyle programme.

These measures include regular exercise and a healthy diet.

Examples of such are:

• Limiting alcohol intake. Red wine is the best alcohol to consume because it contains a powerful antioxidant that protects against heart disease and osteoporosis
• Eat more oily fish (tuna, mackerel, sardines, salmon) and seafood (at least two meals per week) that amount to about 400mg of omega3
• Eat no more than a palm size of protein with each meal
• Increase physical activity, at least 20 minutes five times each week
• Increase mental stimulation
• Avoid fast foods
• Get at least seven hours of sleep each night
• Avoid excess caffeine
• Avoid fumes from pesticides, paints, nail polish, mani/pedicure products and smoke
• Avoid stress and anxiety
• Avoid toxic people

Remember, family history accounts for only 20 per cent of your health. Lifestyle choices greatly impact your outcome and you do have more control than you think.

Vigilant monitoring will detect early cancers and early diagnosis saves lives.

You can also choose to have children before the age of 30.

Preventative mastectomies and removal of normal ovaries are difficult choices that require genetic counselling before those decisions are made.

Unfortunately, when celebrities make such choices it is usually viewed by the public as the right thing to do, but it must be emphasised that women still have a higher chance of developing breast cancer if they are negative for the BRCA test.

Jolie's action was charged not by bravery or courage but by FEAR. What determines our level of courage is how we handle fear.

Albert Einstein said, "We are boxed in by the boundary conditions of our thinking. Mind management is essentially the key to life management. We have the power to choose what we think."

Many times when we are faced with problems we lose confidence in our ability to make the right choices, surrender our control, become paralysed by fear and sometimes do the wrong things. That is when fear becomes a disease.

Dr Jennifer Mamby-Alexander, MD, is a cytopathologist and author of the book 'A Practical Guide to Coping With Cancer'. She is also a 24-year survivor of stage-4 breast cancer and has done bilateral mastectomies with reconstructive sugery.