It is nearly a year since Angelina Jolie made global headlines by speaking out about her decision to have both breasts removed to cut her breast cancer risk.
One year on, new evidence has emerged of the procedure’s benefits for women with a breast cancer gene mutation, which once again raises questions over how strongly it should be recommended for high risk women.
In a small but long-term study in the US and Canada, researchers found that women who had both breasts removed after their first cancer had a 48 per cent higher chance of surviving after 20 years than those who had just one removed.
But experts said that the procedure, though beneficial, could have a huge emotional impact and agreed that it should never be entered into lightly.
Women who carry a BRCA1 or BRCA2 gene mutation have a 60 to 70 per cent chance of getting breast cancer in their lifetime, and also face a high risk of developing a second breast cancer even if one breast is removed.
Although less than three per cent of all breast cancers are caused by these genes, the grim outlook associated with them makes them a major area of research. Angelina Jolie has the defective gene BRCA1, and her announcement that she had undergone a double mastectomy to cut her risk to around 5 per cent significantly raised awareness of the procedure, and of the genetic basis of some breast cancers.
The latest study results, published in the British Medical Journal (BMJ) on Wednesday, looked at 390 patients who had an early stage breast cancer diagnosed between 1975 and 2009. Eighteen out of the 181 who had both breasts removed died within 20 years of their first cancer, compared to 61 deaths in the group who only had one breast removed.
But experts agreed that no amount of evidence should compromise the personal choice at the heart of a woman’s decision to undergo a double mastectomy.
Harvard professor of obstetrics and gynaecology Karin B Michels said that “no statistics and no statistician can make this decision”.
“Statistics remain statistics,” she wrote in the BMJ. “Breasts are, however, not statistics. They are essential parts of women’s identity, sexuality and self-perception. Parting with a breast may result in anxiety, lack of self-esteem and possibly depression. Parting with a healthy breast (or two) to prevent a probability is even more difficult.”
Alternatives to mastectomy for women at a high risk of cancer include preventative drugs, such as tamoxifen, and increased breast monitoring to pick up any tumours early.
Dr Emma Pennery, clinical director of the leading UK charity Breast Cancer Care, told The Independent that there was “no one right answer” when it came to a woman’s treatment and prevention options.
“The negative image on body image and sexuality should also be discussed with the patient. The clinical risk has to be weighed up with the emotional impact,” she said. “It’s important to make that decision based on clear and accurate evidence. We speak to a lot of people who misunderstand what kind of risk reduction they’re getting.
"The most common misconception is that a double mastectomy will improve prognosis of a breast cancer that has already developed on one side. It won’t do that, but it might reduce their chances of dying from a new breast cancer on the other side in the future.”
National guidance in the UK currently advises medical professionals to discuss the risks and benefits of double mastectomy – including emotive questions of sexuality and body image – with women who have breast cancer gene mutations, or an early stage breast cancer diagnosis.
“This dilemma involves coping with the breast cancer you’ve had and worrying about your outcome from that, as well as considering potential secondary cancer and the question of reconstruction surgery, all set against a back-drop of potentially multiple family members who have either been affected or died themselves,” Dr Pennery said. “It’s a really complex area for women to make decisions in, which is why information and support are so vital.”