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Double mastectomy – a drastic measure

A preventative mastectomy might save your life if you are at high risk but it does not provide 100% protection from developing breast cancer.

There is no evidence that a preventative mastectomy – the removal of a noncancerous breast – will completely eliminate the risk of developing breast cancer, said expert Dr Carol-Ann Benn. 

“Preventative mastectomies only decrease the risk of cancer by between 85% and 97%. Nothing can remove the risk of developing breast cancer 100%. The procedure lowers your risk of developing cancer, but does not eliminate it,” Benn said.

She said 10% of breast cancer is caused by malfunctioning BRCA 1 or 2 genes. According to the Breast Interest Group of Southern Africa, BRCA genes are found in all people. When functioning normally, these genes supress the development of cancers. However, when BRCA genes malfunction due to changes called mutations, women have a very high chance – up to 90% – of getting breast cancer during their lifetimes. 

Benn said 60% of cancers occur randomly while 30% runs in the family. “Those who have malfunctioning BRCA genes can develop breast cancer at an earlier age. Breast cancers not related to BRCA mutations are caused by other risk factors such as alcohol, hormones and obesity.”

Last month, actor Angelina Jolie revealed that she underwent a double preventative mastectomy after finding out she carries a malfunctioning BRCA 1 gene that puts her at high risk of developing breast and ovarian cancer. 

Benn however pointed out that there were also other alternatives available to help reduce the risk of developing BRCA–related breast cancer, and that risk–reduction surgery should only be discussed with women considered to be at high risk – particularly those with a strong family history of breast cancer. She said women should visit a unit that can provide psychological counselling to get the best possible advice before deciding to have breast tissue removed. 

“The genetic mutation known as BRCA 1, for which Jolie tested positive and left her with an exceedingly high risk of developing breast cancer, is not common. Less than 10% of women around the world with breast cancer have it,” Benn said.

One in 29 SA women will get breast cancer

According to the national cancer registry, one in 29 South African women will develop breast cancer in their lifetime. “It is the most common cancer among South African women,” said Michael Herbst, head of health at the Cancer Association of South Africa. Herbst said although breast cancer is mainly a disease of women, some men also develop it but it is about 100 times less common among men than women. 

“For men, the lifetime risk of getting cancer is about 1 in 788,” he said.

Justus Apffelstaedt, head of the breast clinic at Tygerberg Hospital in Cape Town, said women who have a genetic risk of developing breast cancer should not rush to have their breasts removed as a way to prevent the condition. 

“Like with any medical procedure, the necessity for risk–reduction surgery for breast cancer is determined by the patient’s understanding of the risk on her side,” he said. “For example, a woman who is found to be a BRCA 1 mutation carrier at the age of 65 may deem the procedure not to be necessary, as her risk of suffering breast cancer is relatively low. Whereas a younger woman in her early thirties with small children at home may feel a responsibility to eliminate all major risks to her health as far as possible to be able to support her young family and therefore choose a risk-reduction mastectomy.” 

Apffelstaedt said this could possibly be the reasoning behind Jolie’s decision as she is in her late thirties and has six children. “A single woman in her twenties may not be thinking about potential health hazards – as she might feel the risk of suffering breast cancer is a distant threat and still wish to breast–feed one day. So a mastectomy may not seem necessary for her at that point in her life,” he said.

Medical schemes

According to Noluthando Nematswerani, a clinical specialist at Discovery Health, a private sector preventative mastectomy costs between R65 000 and R75 000 and breast reconstruction between R75 000 and R85 000. 

“Discovery would cover costs of members requesting to do a prophylactic mastectomy subject to confirmed presence of BRCA genes tied with a strong family history of breast cancer,” Nematswerani said.

The principal officer of the medical scheme, Fedhealth, Peter Jordan, said the scheme covers the costs for a preventative mastectomy depending on each member’s individual benefits. “Fedhealth members have to follow a pre–authorisation process for funding of these procedures. The funding depends not only on a member’s savings accounts, but scheme rules and whether the patients are considered high risk and meet specific clinical criteria or not,” Jordan said. 

“Where members are unsure of how to interpret scheme rules and want to find out what their individual benefits are, they need to contact the member call centre for assistance.”

However, Apffelstaedt said the cost of the procedure shouldn’t be the main consideration when contemplating preventative mastectomy as “virtually all medical aids pay for risk–reduction in proven BRCA mutation carriers”.

“People who suspect that they might have the malfunctioning BRCA genes running their families, can do regular screenings to monitor breast cancer development. But screening alone will not prevent the development of breast cancer, it t will only help with early detection,” said Nematswerani. “Screenings costs of R6 058, which Discovery covers subject to availability of funds and rules of member’s chosen plan type,” she said. 

Nematswerani said although undergoing a prophylactic mastectomy has been shown to decrease the incidence of breast cancer by as much as 90% in people with the BRCA gene, “they must discuss other options with their doctors including the use of medication such as Tamoxifen [medicine that slows down or stops the growth of cancer cells in the body]”. She said these options are less effective alternatives than a preventative mastectomy.