Prophylactic mastectomy is an operation that became widely known thanks to Hollywood star Angelina Jolie, who decided to remove her mammary glands due to a high risk of cancer. Philip Mistakopoulo, a plastic and reconstructive surgeon, oncologist, tells about the history of this operation, its indications and expediency.
Background
The first prophylactic mastectomy - operations to remove the mammary gland - began to be performed in the United States back in the 60s of the last century. Then the basis for the operation could be just a burdened family history, that is, the presence in the genus among the closest relatives in the female line of the disease of the mammary gland. Subsequently, DNA diagnostic methods for identifying patients with a genetic predisposition to developing breast cancer were actively developed in the United States.
Breast cancer is on the rise: more than a million women are diagnosed every year. It is breast cancer that occupies the first place in the structure of oncological diseases in women. According to statistical data, the cause of 5 to 8% of breast cancer cases is a hereditary predisposition.
Modern DNA diagnostic techniques allow identifying patients with a genetic predisposition to developing breast cancer, and performing prophylactic mastectomy with simultaneous reconstruction reduces the risk of developing breast cancer in such patients by 95-97%.
In Russia, prophylactic removal of the mammary gland was officially performed only in 2010, after prophylactic mastectomy with simultaneous reconstruction was included in the List of medical technologies approved for use in medical practice in the Russian Federation. This technique is approved by the Ministry of Health, and in oncological institutions it is used as a guide to action. There are cases when preventive mastectomy with fairly good results was carried out before 2010, but not on the basis of oncological institutions, but in private clinics by oncologists and reconstructive surgeons.
In 2014, the All-Russian Union of Public Associations of the Association of Oncologists of Russia developed Clinical Guidelines for the Prevention, Diagnosis and Treatment of Patients with Breast Cancer.
Indications for mastectomy
Professional guidelines describe when a prophylactic mastectomy may be performed, as follows:
- to prevent the development of breast cancer in healthy women;
- as a prophylaxis for the development of breast cancer in patients with unilateral breast cancer.
The clinical guidelines indicate the following indications for bilateral prophylactic mastectomy in healthy women and in patients with unilateral breast cancer:
The risk of developing breast cancer, according to genetics, exceeds the population risk (including mutations in the BRCA1 and BRCA2 genes);
Morphological signs of an increased risk of developing breast cancer (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ - that is, precancerous diseases of the breast and cancer that has just originated in the duct);
The risk of developing breast cancer is equal to the population or not estimated (that is, in women in whom no genetic disorders were found during the study, or the study was not conducted, but the woman wants to have a prophylactic mastectomy).
The guidelines also state that “Bilateral prophylactic mastectomy for all three of the above indications reduces the risk of cancer by 90-100% and can be performed on healthy women. The operation can be performed both with primary reconstruction of the mammary glands and without reconstruction. It is mandatory to conduct a histological examination of the removed tissues; if cancer is detected, the treatment tactics are determined in accordance with the morphological and biological characteristics of the disease.
Contraindications for bilateral prophylactic mastectomy are:
- old age (women over 65-70 years of age are not indicated for surgery due to somatic indications);
obesity grade 2-3; - hypertension high risk 3 and very high risk 4;
- insulin-dependent diabetes mellitus;
- heart disease;
- infectious-allergic bronchial asthma;
- acute infectious diseases;
- mental illnesses, etc.
Mastectomy Decision Making
The decision on the need for bilateral prophylactic mastectomy is made collectively and is not based solely on the patient's wishes. A geneticist, an oncologist, a surgeon, a plastic reconstructive surgeon and a psychologist participate in the decision-making council for preventive mastectomy. The administration of the medical or scientific center draws up the written consent of the patient with his signature, which is also, as a rule, legally certified by a notary. Thus, the administration of the institution protects itself from any claims of the patient in the future.
Steps of operation
Based on the shape of the breast, a surgical approach is selected at the preoperative stage. So, if the breast is small, then the standard approach is submammary, which allows subcutaneous removal of breast tissue with possible plasty with own tissues or implants. If the breast is large or ptotic (sagging), it is possible to excise excess breast tissue (skin and subcutaneous fat) with the areolar complex moving to a new position.
Prophylactic mastectomy with simultaneous reconstruction is performed in two stages:
- The stage of the actual mastectomy is the removal of the gland tissue itself without skin.
- Reconstruction stage - transfer of a graft from one's own tissues to the area of operation or plastic surgery using an implant and then shaping the shape of the gland using various techniques.
Breast Reconstruction Methods
The following breast reconstruction methods are used for bilateral prophylactic mastectomy:
- replacement of the volume of the removed breast tissue with own tissues using various flaps (which are transferred from the abdomen, back, buttocks, thighs). Both freely transferable and pedicled flaps are used.
- use of silicone implants to restore the volume and shape of the gland, placed in a specially prepared pocket, consisting of the pectoralis major muscle on top, and the treated excess skin on the bottom (in case of ptotic (lowered) glands or in case of glands of large volumes), or from an innovative material - a cell-free dermal matrix, which allows you to cover the implant in the lower part of the mammary gland, protecting it in the early postoperative period from complications such as bedsores or rejection, and such complications in the long term as contracture - cicatricial deformity of the implant.
The easiest method of breast reconstruction is the use of implants. The probability of postoperative complications with this method is relatively high: the most common of them are rejection and contracture of the implant. On the other hand, since this is a less traumatic operation that affects only the breast area, it is easier for the patient to tolerate.
Plasty with the patient's own tissues also has advantages. Own tissues correspond to such biological parameters as body temperature, in addition, the tissue transplanted in the form of a flap feels very close to the patient. But sometimes it is necessary to make a correction, that is, to carry out a second operation to improve the aesthetic appearance and shape of the breast and the nipple-areolar complex.
In terms of long-term effect, the benefits of breast reconstruction with own tissue are clear. But technically, this operation is more complicated and is carried out not in two, but in three stages: first, a mastectomy, then the formation of a flap and its transfer, and then breast reconstruction. Surgeons who replace the removed mammary gland with the patient's own tissues must be highly professional, and the state of health of the operated patient must not be in doubt.
Based on the foregoing, we can conclude that breast reconstruction with own tissues is preferable, but so far there are 10 times more patients who have undergone plastic surgery with artificial materials. Quite a lot of studies abroad have been devoted to this issue, one way or another, their conclusions are similar. In Russia, on the basis of the Department of Reconstructive and Plastic Surgery and Cellular Technologies of the Russian National Research Medical University. Pirogov, a similar study is being carried out.
Where operations take place
Today, in Russia, patients with a diagnosis of breast cancer or a history of a disease and an identified genetic predisposition to the disease can undergo surgery on the opposite, healthy gland in institutions with an oncological license.
If a woman is absolutely healthy and according to the diagnostic methods - ultrasound, MRI, mammography of the breast - there are no signs of breast cancer, then, in accordance with Russian legislation, she cannot be officially operated on in oncology clinics even if a genetic predisposition is identified. But such operations are carried out in private clinics, in agreement with the administration, and, of course, with the voluntary consent of the patient.
Rehabilitation period and possible complications after mastectomy
The rehabilitation period for bilateral prophylactic mastectomy may vary in duration. In case of plastic surgery with own tissues, correction of the mammary gland is sometimes required after 3-6 months (in order to eliminate asymmetry, equalize the volume), in order to achieve a favorable aesthetic result. Sometimes it is necessary to create a new areola and nipple from your own tissues.
Among the early postoperative complications after removal of the mammary gland, infections (suppuration of the wound cavity and rejection of the implant), as well as skin necrosis due to inadequate tissue nutrition are possible.
Late complications are most often encountered with implant plasty and manifest as a change in the shape and density of the breast due to contracture.
Arguments against prophylactic mastectomy
The main argument of doctors - opponents of bilateral prophylactic mastectomy is based on the following dogmatic point of view: if there is no disease of the organ, we have no right to remove it. But this position, in my opinion, is outdated: in the 21st century, patients have the opportunity to undergo a genetic examination and find out what their risks are in the future of becoming a victim of cancer. In oncological institutions in Russia, as well as in commercial clinics and laboratories, it is now possible to undergo a genetic examination. Its results will reliably show whether there is a gene mutation, whether there is a predisposition to breast cancer or not.
If we know that the likelihood of cancer is high, a mastectomy must be performed in order to save life and health. A one-time reconstruction, carried out by a professional plastic surgeon, also allows you to restore the beauty of the woman's breast. Sometimes the aesthetic effect of this operation exceeds all expectations of the patient.
Patient satisfaction with prophylactic mastectomy
In the United States, studies were conducted on the degree of patient satisfaction with the results of this operation and a special assessment scale Breast Q was developed. This scale assesses the psycho-emotional state of a woman, the aesthetic result, the quality of life after surgery, as well as the quality of services in the clinic, the woman's satisfaction from communicating with medical personnel and the long-term result of the operation. The results of studies, as a rule, show a high degree of patient satisfaction with the operation performed - more than 80%.
According to 1nep.ru
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