Risk reduction surgery
Beyond the trauma of being diagnosed, cancer in women – as well as its treatment – has a number of life-changing implications, hormonal and otherwise. We explore risk reduction surgery as a method of maintaining quality of life and preventing female-specific cancers.
Breast cancer may be the most common female-specific cancer in South Africa, but cervical cancer is more likely to cause death. In 2015, it was the second leading cancer killer, claiming the lives of 5 400 women. In addition, women have a 1 in 75 chance of getting ovarian cancer in their lifetime – ranked fifth in cancer deaths among women across the globe. In light of these statistics, should women who are at high risk for developing these cancers mitigate their risk before the cancer develops – or is such an invasive approach unnecessary?
Preventative measures or over-treatment?
American actress Angelina Jolie made headlines in 2015 when she opted to have her ovaries and fallopian tubes removed to mitigate her risk of ovarian cancer. After her preventative double mastectomy two years before, the decision to forego her ovaries and fallopian tubes seemed like a drastic measure that many deemed as over-treatment.
But, as she revealed in her op-ed for The New York Times, a blood test had revealed she was a carrier of a mutation in the BRCA1 gene (the protein in the BRCA1 gene repairs DNA, and is found in all humans). Her mother died of ovarian cancer at the age of 49, and before that her grandmother and aunt had also succumbed to cancer. Angelina’s estimated risk for breast cancer was 87%, and 50% for ovarian cancer.
Dr Etienne Myburgh, an oncology surgeon at Panorama Mediclinic, explains that in terms of a woman’s risk of developing cancer, there are various categories. Someone who carries one of the high-risk genes (BRCA1 and 2, and P10, etc.) would be in the category with the highest genetic susceptibility for actually developing cancer. The other categories are where environmental factors would play a big role to ‘activate’ the cancer.
‘If I know that someone has a genetic risk for developing cancer, I think it is a reasonable option to look at risk reduction surgery to maintain their quality of life,’ says Dr Myburgh.
Dr Omondi Ogude, a medical oncologist at Sandton Oncology Centre, says only a minority of breast and ovarian cancers have distinct genetic associations, so looking at the family history is one way to ascertain a patient’s risk for any specific cancer. He says the BRCA gene is probably the best-known gene to account for genetic breast cancers.
‘We do know that of the patients who have this gene, about 60% could be called an absolute risk: by the time they reach the age of 60 they will almost certainly have breast cancer,’ says Dr Ogude.
Dr Ogude says over-treatment is becoming an issue because cancer is increasingly being diagnosed early (through screening and mammography). He adds that there is a lot of evidence to suggest that some of these very early precancerous lesions being identified in mammograms may not progress into anything significant or worrying (if left untreated). ‘Patients become extremely anxious and they go for biopsies, surgery and finally the trauma of (possibly unnecessary) chemotherapy and/or radiation.’
While in Angelina Jolie’s case he believes the surgeries were not entirely inappropriate, Dr Ogude cautions that she is part of the very small minority of cases where such an invasive approach would be necessary.
A staged approach
Dr Myburgh believes risk reduction surgery is a reasonable option only where a risk exists, but adds that it’s a question of when is the most appropriate time to have it.
For example, the risk for breast cancer is pre-eminent in younger women, in comparison to the risk for ovarian cancer. ‘We don’t have to go ahead and remove both breasts, fallopian tubes and ovaries all at once,’ he advises, adding that staged treatment would be better.
‘If your risk is high, have a mastectomy first, at a younger age. With the reconstruction, you’re going to need about a three-month recovery period, but you still maintain your femininity and hormone levels.’
Dr Myburgh adds that when patients are getting towards the age of 40, they can consider having the tubes between the ovary and uterus removed.
‘Many of the ovarian cancers originate in the tube, not in the ovary. So you still keep the ovary with all the patient’s natural hormones. When she is in her late 40s, one can theoretically remove the ovaries when the patient is entering natural menopause anyway,’ says Dr Myburgh.
Dr Ogude advises that, whether or not this route is right for the patient, it should be explored together with a genetic counsellor and a medical oncologist, who can discuss the pros and cons.
‘Can we overtreat patients? Yes we can, if we just treat everything at a young age,’ says Dr Myburgh. ‘But equally, can we undertreat them? Definitely. If we wait until the person has cancer, they have all the side effects of the cancer itself plus the treatment involved. That’s a big price in terms of quality of life.’