Prophylactic Mastectomy: A Reasonable Option?

Since Angelina Jolie’s news, I’ve seen several points repeated, so I’ll address them:

“She should have waited until she actually had cancer.”

This actually reflects several misunderstandings: of Cancer itself, a confusion between systemic and localized cancer, and a lack of knowledge about mastectomy procedures. She couldn’t have had the surgery she had if she had waited until she had cancer. What she had is a “skin-sparing prophylactic mastectomy” the point of which is to remove as much breast tissue as possible while giving a result that is not obtainable with reconstruction after cancer surgery. Compare the pix below:

Pretty big difference isn’t there? The first looks natural and the second is designed to look natural in clothing. The scars from biopsies and mastectomy really can’t be hidden that easily.

The other problem with actually waiting and relying on so-called early detection is that it assumes that a mastectomy could or should be done at that point when it is not always the best option. Cancers may be local or systemic and just because a cancer is small does not necessarily mean that it was caught early or that it will be easy to treat. A small cancer could be a very aggressive cancer with tendrils reaching into other organs that would need to be treated with radiation, chemotherapy or other treatments and skin that has been scarred and irradiated is not always capable of being stretched over an implant. Essentially, once you have a malignant tumor, you are no longer having a “prophylactic mastectomy” because breast cancer may be in other parts of your body besides your breasts as author Kelli and her sister, Fran, discover in this article, MY SISTER HAD A DOUBLE MASTECTOMY TOO, BUT SHE DIED OF BREAST CANCER ANYWAY.

This is similar to what happened to my mother. For those of you who haven’t read it before, Mom had breast cancer which was treated by lumpectomy and radiation. She had the requisite followups of mammograms and biopsies and when she was diagnosed with metastasized breast cancer in her lungs, liver and spine twenty years later, her breasts were clear of cancer. So if she had a so-called “prophylactic mastectomy” at the first sign of cancer, she would have had the same thing happen.

Obviously “preventive” means before cancer is diagnosed. If you want an approachable but still gratifyingly educational book about cancer, check out The Emperor of All Maladies by Siddhartha Mukherjee.

Here is another absurd yet oft’ repeated statement…

“No ethical doctor would ever remove a perfectly healthy set of testicles from a man who has no symptoms of testicular cancer, so how could a doctor do this?”

Here we have both medical ethics and sexism rolled into one question. The quote brings to mind all the tabloid scandals since the 60s from medically unnecessary hysterectomies, (the so-called Harlem appendectomy) to DES, from C-sections to prophylactic mastectomies… never mind that this time it is the women asking for the procedure. There are a couple of things that really irk me about this statement.

1. Testicles aren’t analogous to breasts, but to ovaries, and as important as these are women do get them removed much more cavalierly than they remove breasts. Breasts actually have little function aside from breastfeeding infants and Jolie and most other women who are in the age group to be considering this procedure have probably already done that.

2. Since cancers affect lungs, pancreases, stomachs, and plenty of organs that can’t be removed preemptively, does that mean that something that can be, shouldn’t be? These women are educated, can generally afford the procedures if not covered by insurance and are making their decisions with their doctors. Is that really different than any other elective procedure?

Bonus round: Right now, neither genetic testing nor prophylactic mastectomy is usually recommended by physicians but if Aetna’s policy posted online here is indicative, prophylactic mastectomy medically necessary for reduction of risk of breast cancer it may be recommended by insurance providers at some point.

I know this is controversial stuff, so please be thoughtful of others feelings when you comment.

Related articles:

• Prophylactic Mastectomy: Angelina, Sharon and Me (dunthor.com)

• Here is a link to a Daily Mail article about 4 young UK women who discuss their reasons for having this surgery.

• Here is a link to an article by a woman who says she delayed having a prophylactic mastectomy and then did get cancer.

• Skin sparing Mastectomy film on Youtube from Johns Hopkins