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From the Jewish Exponent:
Lumpectomy, Mastectomy & the Controversy Over Prophylactic Double Mastectomies with Dr. Lisa Jablon, director of the breast program, Einstein Medical Center’s Marion Louise Saltzman Women's Center and Dr. Jennifer Chalfin Simmons, Chief of breast surgery and director of the breast program, Einstein Medical Center Montgomery.What are surgical treatment options for breast cancer?Dr. Jennifer Chalfin Simmons explains that the general categories of breast cancer surgery are lumpectomy and mastectomy. “Once the patient has been diagnosed and fully evaluated, we discuss the surgical treatment that best suits her,” she says. “My job is to help patients understand the facts and make a sound decision. But there is no ‘wrong’ decision. Whatever a woman decides is what is right for her.”Regardless of what kind of surgery they have, the overall treatment plan may include radiation, chemotherapy, or antihormonal therapy, which is also known as endocrine therapy.What is the timeline for surgery?“If we do a lumpectomy or mastectomy without reconstruction, it happens within a week or two of diagnosis,” Simmons says. “If we are doing mastectomy with reconstruction, then we need to coordinate schedules with the reconstructive surgeon. We try to have that surgery happen within one month.”Who should consider a prophylactic double mastectomy?The first step, Jablon and Simmons explain, is to determine – to the best of their ability – a woman’s risk for developing breast cancer. That begins with an accurate family history of breast and ovarian cancer. Should that history show a prevalence of those cancers, the next recommended step is genetic testing for the BRCA-1 and BRCA-2 genetic mutations.*For more on genetic testing, read “BRCAs Decoded: Understanding Genetic Testing for Breast and Ovarian Cancer” with Dr. Adele Schneider, director of clinical genetics and medical director of the Victor Center for Jewish Genetic Diseases at Einstein Medical Center. But women who test negative for BRCA mutation might still be at risk if they have a family history of breast and ovarian cancer. Genetics other than the BRCA mutations might be involved. But, science has not yet identified those other genes. “There are families in which there is clearly a predisposition for cancer,” Simmons explains. “The problem is that we do not have a way of giving a realistic risk analysis to that patient.”What is there to do? Increase screening is the first step, the physicians explain. “A patient with breast and ovarian cancer in her family history – even if she does not carry the BRCA mutations – should have imaging studies twice a year so that, through increased surveillance, we can catch any cancer that forms,” Jablon says. What about prophylactic double mastectomies? Jablon and Simmons discuss the surgery with patients who have a strong family history of breast and ovarian cancer and test positive for a BRCA mutation. They also have the discussion with patients who have had breast cancer in one breast before the age of 50. Those patients are at increased risk for developing cancer a second time.Jablon gave an example of when she advised the procedure. “I have a 26-year old in my practice who has cancer in one breast,” Jablon explains. “The patient tested negative for the BRCA mutation and does not have a family history of breast cancer. But the fact that she has breast cancer at such a young age means that she has an increased risk of getting cancer in her other breast. I would counsel her to consider a prophylactic mastectomy.”But if the patient has not had breast cancer herself and she tests negative for the BRCA mutations, a strong family history of breast or ovarian cancer does not – in and of itself – mean that a prophylactic double mastectomy is advisable.Simmons considers other factors before recommending that surgery. “One of those factors I look is the density of the breast tissue,” Simmons explains. “The denser the tissue, the higher the risk. I also evaluate her emotional fortitude and talk to her about what kind of anxiety she can withstand. If she is anxious and afraid and will spend her life anticipating breast cancer – and that can be alleviated by prophylactic surgery – then I advise it.“But if the patient’s quality of life will not be severely altered by the knowledge that she is at high risk, then I might recommend Tamoxifen, which can reduce the occurrence of breast cancer by 50 percent,” Simmons says. “I also recommend she have twice annual mammograms.”What about prophylactic oophorectomies?Jablon and Simmons agree that prophylactic oophorectomies – removal of ovaries – are highly effective prevention for women who have a strong family history of breast cancer. “Having an oophorectomy before age 40 reduces a woman’s risk of breast cancer by more than 60 percent,” Jablon says. “And of course, removing the ovaries greatly reduces the risk of developing ovarian cancer.“In fact, I counsel women to consider an oophorectomy more than a prophylactic mastectomy,” Jablon says. “That’s because we do not have effective for screening for ovarian cancer, so we don’t usually pick it up until it develops, and then, it can be very aggressive.”Simmons agrees. “But I am very pleased that we have made great strides against breast cancer,” she says. “Now, because so many women get mammograms and the technology has made great advances, we are catching breast cancers early, and curing them. Now, most of us who treat breast cancer are dealing largely with issues surrounding survivorship. What is survivorship? It’s how you live the rest of your life after we cure you of breast cancer.”