Twenty years ago the idea of undertaking bilateral mastectomies for a woman who had not been diagnosed with breast cancer was not only an anathema, frankly, it was considered unethical.
As a surgeon looking after women who had been diagnosed with breast cancer, I had embraced and begun to innovate techniques of breast reconstructive surgery after cancer surgery, not only for women to have the greatest chance of being cured, but also so that they could function fully and feel as natural and normal as possible.
When my clinical genetics colleagues began to identify women who were at very high risk of developing breast cancer, but who had not yet developed the disease, there was a dilemma. It was already known that breast cancer associated, inherited gene mutations existed, and we now know that women with BRCA1 mutations result in a particular type of breast cancer known as triple receptor negative. These cancers can grow and spread rapidly and are difficult to treat as they can recur early.
Slowly but steadily women from families with a history of these breast cancer associated, inherited gene mutations began to appear in my clinics, requesting bilateral mastectomies with total breast reconstruction in advance of being diagnosed with cancer. Initially I baulked from choosing to perform this surgery, but when one of our own nurses found she was carrying a gene mutation, I changed my mind. At this point, I was persuaded to undertake the surgery, and the pathologist found the earliest pre-cancerous changes already in the tissue removed from her breasts. Eighteen years later my ex patient, has had her reconstructive implants renewed, she looks natural, and has so far avoided breast cancer.
The last ten years has seen great improvements in our understanding of the breast associated genes. During this time, I have always worked in close conjunction with breast cancer family history teams, a clinical geneticist, a psychologist, radiologists and pathologists. In order to protect patients, we wrote a protocol for the management of women at high risk, stipulating that we would only consider women for surgery who had a 1 in 4 calculated risk of having or developing breast cancer. In reality, most of these women's risks were much higher. Those with a BRCA1 mutation bear more than an 80% risk of developing breast cancer, and in the early days, these patients were true pioneers and fought hard to have this surgery.
May 2013 was a turning point as Angelina Jolie publicly announced that she carried the BRCA1 gene and that she had undergone an elective double mastectomy and reconstructive surgery. The media coverage around her generated increased discussion and a greater understanding of the BRCA1 gene and the choices available to those at risk. This in turn led to an understandable increased demand by women to have their risk assessed and to make enquiries regarding risk reducing surgery and breast reconstruction.
It is essential that surgery is not undertaken lightly, nor for the wrong reasons for the wrong patient. What Angelina and discussion around her journey has done, which is so important, is to open up the whole debate into the public arena.
No longer unusual, there is now a steady flow of women requesting assessment for breast cancer risk and wanting to consider mastectomies with breast reconstruction if they are calculated to be at significant risk of developing breast cancer.
Of course, it is crucial that surgeons are highly specialised and highly trained, and that they have experience of this sort of undertaking. It is difficult, complex surgery with many pitfalls and possible complications to be avoided wherever possible. Working within a team is essential. King Edward VII's Hospital in London in the independent sector, provides a service where women can be formally and scientifically advised, where genetic tests can be undertaken where appropriate, and where patients have the highest quality surgery extended to them should they wish to proceed with it.
Looking back over the last 20 years, I have personally undertaken almost 400 risk reducing operations for individual patients, mostly with breast reconstruction, which has become so refined in recent years that breast reconstruction looks no different from good aesthetic surgery. It is no longer 'mutilating' surgery. Even nipples needing to be removed can be recreated exactly, and for many it is possible to preserve the woman's own nipple areola complex, leading to great results for natural looking breasts.
What is also worth noting, is that data now exists to validate the whole process. It is now scientifically proven and published in peer reviewed journals that using surgery reduces the incidence of breast cancer diagnosis by over 90%. That means that the therapeutic benefit of the surgery for those at high risk is substantial.
Over the last two decades, it is clear that risk reducing surgery and breast reconstruction, continues to offer significant advancements for the prevention of breast cancer, and indeed mortality rates, through premature diagnosis. For a patient at high risk, there is no better option at present.