Two prominent Memphis physicians, Christine Mroz, a breast specialist and surgeon, and Karen Quigley, a plastic surgeon, agree that while there have been major advances in the genetics of cancer as well as the use of team surgery approaches, patients being treated for the disease frequently do not fully understand their options.
Mroz and Quigley, who often team on breast surgeries, both say they are seeing an increase in bilateral mastectomies but would like to see an increase in broad-based patient awareness as well.
Their hope is that the improvement in genetic testing will help patients better understand their risk for certain cancers, including breast, colon and pancreatic. Mroz recalls that 15 or 2o years ago only a few genes of the human body’s 36,000 genes were tested and the testing was not covered by insurance. Now, most insurance covers the testing and it’s a panel of 30 genes linked to cancer, not just two.
For breast cancer, physicians look for the BRCA1 and BRCA2 genetic mutations. According to the National Institutes of Health, “BRCA1 and BRCA2 mutations account for about 20 to 25 percent of hereditary breast cancers and about 5 to 10 percent of all breast cancers. Breast and ovarian cancers associated with BRCA1 and BRCA2 mutations tend to develop at younger ages than their nonhereditary counterparts.”
Women who have a strong family history and sometimes multiple abnormal mammograms are the best candidates for genetic testing.
“It’s not like everyone should get genetic testing,” Quigley said. “Patients getting genetic testing usually have other family members with breast and/or ovarian cancer.”
Patients who receive positive genetic results but who have not developed cancer yet are in a unique position, different from, say, their mothers or grandmothers who were diagnosed with cancer.
Without the cancer diagnosis, but with positive genetic result, there is a difficult decision. Women as young as 24 are deciding to remove both breasts to lower their risk of cancer.
Gene-positive patients "don’t take it as well, losing their breast. They question, ‘Did I really need to do this?’” Quigley said.
The community is also catching up to accommodate these patients who do not fit the traditional mold of breast cancer survivor, but nonetheless need support.
Some patients think a bilateral mastectomy will increase survival, but a lumpectomy during early stage cancer can have equal survival rates. Mroz explains, “Removing both breasts does not increase your survival because survival depends on the biology or genetics of the tumor.”
There is a certain amount of risk to a mastectomy, such as increased drainage and infection.
However, patients with cancer in one breast and BRCA1 or BRCA2 mutation have a greater chance of developing cancer in the other breast, and a bilateral mastectomy is considered. When deciding about surgery, other factors include the size of the breast and age of the patient.
Mroz and Quigley treat patients with the team approach – a patient begins with Mroz, discussing the biopsy and options for removing the cancer. Then they follow up with Quigley to discuss reconstructive surgery, which will be performed in the same procedure as the mastectomy. While this model is not new, it improves the patient experience for both gene-positive patients and breast cancer patients.
Mroz says “Patients want answers right away, so we try to bring it all at the same time.”
She said that in the late 1970s and early 1980s when it was first being done, “no one was doing immediate reconstruction. Now almost everyone is eligible for immediate reconstruction.”
Patients have responded positively to the approach. Quigley notes that patients want to know their options, including the options for reconstructive surgery, which have improved. Usually by the end of the appointment with her, patients have made a decision whether or not to undergo reconstructive surgery immediately following the mastectomy.
Many patients do not realize that insurance will cover operating on the opposite breast for symmetry, and some patients opt for bilateral mastectomies with reconstructive surgery. The benefits to planning reconstruction before the mastectomy include less trauma to the tissue and fewer surgeries.
One new approach in plastic surgery is two-stage implant reconstruction. The plastic surgeon’s first step, after the mastectomy surgery, is placing a tissue expander or empty saline implant. The implant is injected with saline through a valve in the skin over a few weeks.
This method puts less stress on the skin and gives the skin time to stretch. In the second step, the surgeon removes the expander and inserts the permanent implant. In the two-stage reconstruction the second surgery also gives the plastic surgeon time to perfect the implant. Quigley says two-stage reconstruction "lets the patients say ‘OK, we’re going to start on this, then see what size you want to be and figure that out slowly.’”
What’s next for breast cancer treatment? Both physicians see improvements to chemotherapy on the horizon, noting how far chemo has come from the days when a patient with multiple positive lymph nodes had a short life expectancy, to now having multiple paths to treatment and a normal life expectancy.
Research at Vanderbilt and MD Anderson on links between specific cancers and genes to improve chemotherapy effectiveness will improve therapy. Mroz says “molecular genetics of the cancer is guiding treatments.”
RELATED LINKS: