I’m not looking for medical advice here…
On Grey’s Anatomy, a woman comes in who’s mom, cousin, etc. all have breast or ovarian cancer. She wants to have a double masecotmy and a hysterectomy in order to eliminate her chances of dying of cancer.
My understanding is that if ovarian cancer and breat cancer are caught early, they can be cured. Is this true? If so, would this scenario really happen, or would she just come in for more frequent pap smears and mamograms?
AFAIK, it is an option for women who have a family history and the gene for breast cancer, to have a double mastectomy as a preventative. I’m not sure about the hysterectomy, but given the sheer numbers of women that have them every year, I don’t imagine it would be hard to talk your doctor into doing it.
haven’t seen the show.
If you have the wrong genes and a strong family history you can have a 50% or higher chance of developing breast and/or ovarian cancer and/or bowel cancer.
That is not good odds.
Ovarian cancer is rarely caught early and so doesn’t have a great prognosis. It is not diagnosed by pap smears (that’s cervical cancer). The only diagnostic tests are ultrasound and blood tumour markers, but they’re not very accurate and may lead to unnecessary laparotomy or missed diagnosis.
In some cases with a very high risk it may be felt that a prophylactic hysterectomy and bilateral salpingo-oophorectomy may be safer and more wothwhile as it totally removes the risk of developing the ovarian cancer.
The reason for removing the uterus along with the ovaries is thus.
Removing the ovaries in a pre-menopausal woman will catapult her into premature menopause, so she will need HRT to prevent osteoporosis and the other symptoms.
Oestrogen only HRT has a lower risk of breast cancer than combined therapy, but is only safe to use in women who have no uterus, as it can cause endometrial (uterine) cancer.
For this woman, having her ovaries removed is probably the more important of the two operations, and the double mastectomy less so, however, as she woud need HRT, and HRT is associated with an increased risk of breast cancer, it might be the safest thing to do.
This is one of those things where you give the patient all the information and let them make their own choice. For some people the mastectomy and hysteretomy is better than having a sword of Damocles hanging over their head for the rest of their life, especially as they have already seen what the illness can do to those they love.
For others the psychological impact of such major surgery would be worse than coming in for a 6 monthly work-up and the chance that it could always be cancer.
In short, yes, this is a real scenario, and this can and does happen.
Thanks, I appreciate it.
Oh, I forgot something important.
In countries without universal health care, decisions might also be motivated by the patient’s finances.
For example, your life insurance premiums might be incredibly high because of the genetic risk, and they may reduce if you had the surgery.
Your health insurance might also be astronomical, and could reduce after the surgery.
Perhaps your insurance wouldn’t cover prophylactic surgery, but would cover frequent screening and cancer treatment.
Perhaps your insurance would cover prophylactic surgery, and cancer treatment, but NOT the frequent screening you’d need to catch the cancers early enough to save your life.
Everyone wants to live a long, healthy life, but few want to do so at the cost of bankrupting their family or depriving their children of an inheritance.
OK, I am a doctor, but I am not an oncologist, and everything I say here should be regarded as general info. Please don’t base any individual medical decision on my statements - talk to your own physician.
Cancer detected earlier is easier to treat than cancer detected at a late stage because if there has not been metastasis of the original cancer to other locations in the body, surgical decision of the original mass (or organ containing the mass) can potentially be curative. However, certain cancers tend to spread aggressively, so that even if they are detected early they may have already metastasized. Once metastatic spread has occurred, adjunct therapy such as a chemotherapy or radiotherapy is necessary. These adjunct treatments carry very unpleasant side effects, and have no guarantee of success.
In general, people who are considered very high risk for a particular malignancy do receive frequent screening evaluations. However, prophylactic bilateral mastectomy is offered to women who have either extremely high risk based on family history or test positive for one of the breast cancer genes.
Here’s a segment from a reference source called UpToDate which reviews medical literature and offers summaries. I think my posting the segment of it here counts as fair use. Be forewarned, it’s not easy reading.
CLINICAL DECISION MAKING — Clinical decisions about whether to pursue increased surveillance or prophylactic surgery are difficult dilemmas that may involve a trade-off between duration and quality of life. Several tools (called decision aids) are available to help with decision making; most use the concept of time tradeoffs (ie, years of life saved by one strategy as compared to another) [53-55]. Although this represents a valid method to assess preferences [56], these models are better for estimating cost-effectiveness than for clinical counseling. Decision-making with a clinical genetics counselor by weighing the pros and cons of alternative strategies is easier for patients to conceptualize than the concept of time tradeoffs, and takes individual patient preferences into account. Decision aids may be more valuable in areas where non-physician genetic counselors are scarce (ie, outside of the United States).
The importance of patient preference can be illustrated by one model that compared life expectancy (LE) and quality-adjusted life expectancy (QALE) from four strategies: prophylactic mastectomy and prophylactic oophorectomy; screening for breast cancer and prophylactic oophorectomy; prophylactic mastectomy and screening for ovarian cancer; and screening for both breast and ovarian cancer [57]. Among the assumptions were that: bilateral prophylactic salpingooophorectomy (BSO) decreased the risk of ovarian cancer by 95 percent, and the risk of breast cancer by 76 percent if done prior to age 40, while the risk reduction for breast cancer was less (40 percent) if BSO was performed between ages 40 and 50; prophylactic mastectomy reduced the risk of breast CA by 90 percent.
For a hypothetical 30-year-old mutation carrier, prophylactic mastectomy and oophorectomy provided the best increment in life expectancy (LE, by 11.7 and 6.6 years) for women at high (85 and 63 percent risk of breast and ovarian cancer, respectively) and medium (56 and 16 percent risk of breast and ovarian cancer, respectively) risk, compared to screening for both cancers. However, when patient preferences were taken into account (QALE), prophylactic oophorectomy and breast cancer screening represented a better strategy both for women at medium risk, and in young women at high risk, when oophorectomy was performed before age 40.
One scenario where a decision analysis aid has been useful is regarding the influence of hormone replacement therapy (HRT) on the risk of breast cancer in women who have undergone prophylactic oophorectomy [58]. (See “Decision analysis”). This Markov decision analytic model to assess the expected outcomes of prophylactic oophorectomy with or without HRT (to age 50 or for life) suggested that short-term HRT does not negate the benefits of prophylactic oophorectomy in reducing the risk of breast cancer. The authors concluded that HRT should be considered for quality of life issues rather than its influence on life expectancy. (See “Prophylactic salpingo-oophorectomy in women at high risk of ovarian cancer”, section on Hormone replacement therapy).
Shared decision making interventions — Because an individual patient’s values assume a prominent role in choosing therapeutic strategies, there is a movement toward greater patient involvement in decision making. Shared decision making aids are increasingly being developed for situations, such as cancer risk management in BRCA mutation carriers, where there is no clear preferred course of action [59,60].
The effect of a shared decision-making intervention (SDMI) on well-being and treatment choice was studied in a trial that randomly assigned 88 known BRCA mutation carriers to undergo SDMI two months after the test result, or to not receive it (the control group) [59]. The SDMI consisted of two value assessment sessions followed by individualized treatment information based upon QALE. Although there was no short-term benefit of SDMI at three months, women undergoing SDMI had significantly less intrusive thoughts and better general health at nine months, and tended to be less depressed. There was no effect of SDMI on the decision to undergo prophylactic mastectomy.
This tool did not appear effective for BRCA mutation carriers who had breast cancer. This is not an unexpected finding, since one would expect unaffected women to have more conflict about medical decision-making and possibly more distress, while decision making may be more straightforward for breast cancer survivors.
MANAGEMENT OPTIONS FOR HIGH-RISK WOMEN WHO DEVELOP BREAST CANCER — Women from high-risk families who are diagnosed with breast cancer may wish to undergo BRCA1/2 testing prior to making definitive surgical decisions [61]. Given the fact that BRCA1/2 carriers have an increased risk of ipsilateral and contralateral breast cancer, women who test positive may wish to undergo bilateral mastectomies, even if they are candidates for breast conservation therapy (BCT) [62].
BCT is an appropriate option for local treatment [62,63]. Relative to age-matched controls with localized breast cancer who are not mutation carriers, the rate of local failure at 5 years or less is no higher in mutation carriers, and there does not appear to be a higher rate of acute or chronic radiation-associated complications in carriers. (See “Techniques and complications of breast and chest wall irradiation for early stage breast cancer”, section on Radiation therapy in BRCA I/II carriers and see “Mastectomy and breast conserving therapy for invasive breast cancer”, section on Inherited susceptibility).
However, the increased rate and late time course of ipsilateral second primary breast cancers (which predominate rather than local recurrences) suggests that carriers should be informed about options that address this risk, as well as the increased risk of a contralateral breast cancer. In addition to contralateral prophylactic mastectomy [64,65], the risk of a second primary breast cancer may be offset by tamoxifen, which reduces the risk of contralateral breast cancers in carriers by 50 percent, as does oophorectomy [2,41]. However, the ability of tamoxifen to reduce the risk of a second breast cancer in newly diagnosed carriers with ER-negative breast cancers remains unclear [66]. (See “Selective estrogen receptor modulators for the prevention of breast cancer”, section on Tamoxifen for BRCA1 and BRCA2 carriers).
With regard to decisions about adjuvant chemotherapy, current data regarding the impact of BRCA1/2 status on breast cancer related prognosis are inconclusive, and thus mutation status generally does not factor into the decision making process regarding systemic treatment options.
For carriers not opting for bilateral mastectomies, surveillance with clinical breast examination, mammography and MRI is recommended, as outlined previously.
RECOMMENDATION — For women who have a genetic mutation that predisposes them to breast and ovarian cancer, the available options of prophylactic surgery, intensified surveillance, and chemoprevention should be explained in detail, and the comparative benefits of each of these strategies discussed with each patient and her family. There is no clear “best” choice among these alternatives; it is highly dependent upon the patient’s own set of values. Although the strategy of bilateral oophorectomy and mastectomy may provide the greatest degree of risk reduction, the impact on quality of life cannot be trivialized, and residual risks for malignancies remain. The clinician’s job is to make the information about each option as clear as possible and to support the patient in the decision-making process.
A summary of our recommended approach to these women is detailed in Table 2 (show table 2). The estimated impact of different combinations of therapeutic options on breast and ovarian cancer risk in women with genetic mutations is summarized in Table 3 (show table 3).
If I may, I’ll note that while this is widely accepted medical opinion, and there is some evidence for it, it is not medically proven AFAIK; last I heard, a meta-analysis of all the HRT breast cancer studies showed a slightly higher breast cancer risk, but not a statistically significant one. That’s two years ago or more, so things may have changed.
–Cliffy
Longterm use of HRT is related to increased risk of breast cancer, was confirmed by the Million Woman study and if you’re talking about a person with a greater than 50% chance of breast cancer anyway (as opposed to the average Irish woman’s 1 in 11 lifetime risk) even a tiny avoidable increase in risk is not something you want to take chances with.
Cite:http://www.bupa.co.uk/health_information/html/health_news/190803hrt.html