Ask Dr. Barber

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Q. I recently had the breast cancer gene test and was found to be BRCA2 positive. My mother died of breast cancer at 40 and I am now 36. My mammograms are clear so far but I have been advised to consider removing both of my breasts to protect myself from the disease. What is the best form of reconstruction for double mastectomy if I chose to go this route?

A. I applaud you for having the gene test for breast cancer. You now can take some control over the disease rather than the disease having control of you. As you have probably been informed, there are two genes that are commonly evaluated to see if a patient has an increased risk of breast cancer, BRCA1 and BRCA2. BRCA is an abbreviation for BReast CAncer. Both of these genes normally have a protective effect to limit the chance of malignant transformation of breast cells, but in a certain percentage of the population, both men and women, the gene undergoes a mutation which increases the chance that a person will develop breast cancer. If a person is BRCA1 positive, then the risks of developing breast cancer by age 70 is between 55% and 65%. If you have the BRCA2 mutation, then the risk is about 45%. The risk of developing breast cancer in the general population is between 8%-12%. It should be emphasized that this gene mutation also increases the risk of ovarian cancer, so it is not unusual for the oncologist to recommend the removal of the ovaries. 

Now that you know that you have the mutation, and that your mammogram is clear, you have the luxury of evaluating your options without a rush to treatment. As for reconstruction, there are a number of options. First, you can decide to use some of your own tissue to reconstruct the breasts. It can come from your lower abdomen, upper inner thighs, lower buttock area, and upper buttock area. The donor site often will depend on your body type and the experience of your surgeon. Surgeons often have favorite donor sites and will sometimes steer a patient in a particular direction. The second option for reconstruction is to use breast implants. Implant reconstruction is technically an easier procedure and has a shorter recovery time. However, implants do not last a lifetime, like your own tissue will, so they will have to be replaced about every 10-15 years. One of the newest and more popular reconstructions that is being done today in women undergoing prophylactic mastectomies, without any evidence of cancer, is nipple sparing mastectomy with direct to implant immediate reconstruction. If you are a candidate for this type surgery, you can be left with almost normal looking breasts after the reconstruction. On a personal note, my sister-in-law was found to be BRCA2 positive. Her other 3 siblings were tested and all found to be positive. All underwent prophylactic mastectomy (including the brother) and 3 of the 4 were found to have breast cancer. My sister-in-law had the nipple sparing mastectomy with direct to implant reconstruction and her results from the reconstruction are fabulous. I would recommend that you see at least 2 plastic surgeons for a consult and also ask your breast surgeon to see if you are a candidate for nipple sparing mastectomy. Good luck!

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