Created on 25th September 2008
Three sisters carry the breast cancer gene; two have fought the disease and lost their breasts, while one chose to have her healthy breasts removed and reconstructed. Jenny Pitt finds out how they coped
When Judy Lawrence, 49, from Worcester Park, Surrey first felt a lump in her right breast five years ago, she calmly waited a week before visiting her GP because she was having her period. A month and several hospital tests later, Judy's worst fears were confirmed when she was told she had a grade 3 malignant tumour in her breast. The NHS consultant recommended that Judy have a mastectomy to remove the breast. Although he was willing to perform reconstructive breast surgery after six months, he wanted to concentrate on removing the tumour as soon as possible to ensure that the cancer had gone.
Judy didn't care about reconstruction at this stage, it was the last thing on her mind - she was terrified that the cancer might spread. "It was an awful, horrible time. I couldn't plan anything - I just wanted it gone," she explains.
When she woke up after the surgery, she had one strong emotion that outweighed every other, sheer relief. "You have a clear plastic strip after surgery, so when I took my top off, I could see straight away, and it looked horrible, but I thought, ‘that's lovely, it's gone'."
A few months later in July, Judy suffered another blow. Her genetic testing indicated that she was carrying the breast cancer gene, known as BRCA-1. Judy was frightened the cancer would return, so she decided to have her left breast removed in a second mastectomy. The breast wasn't cancerous and there was no need to remove any lymph nodes (21 were removed in her first op).
Incredibly, Judy actually felt better when her second breast was removed, more balanced and worry-free. "I just felt like I was flat-chested and I was happier with no breasts." An overwhelming emotion for a woman who had always been busty and curvaceous, and who considered her breasts her best assets. She adored lacy, sexy lingerie (she still does) and her breasts were important to her sex life. "They played a big part and I do miss them," she says.
She goes on to explain, "One breast was diseased and I didn't want it, and I lost the other one because I wasn't willing to take the risk of the cancer coming back. I felt deformed with one breast." The subject of reconstruction came up with her consultant but Judy didn't feel like she wanted to. She accepts that if she had been younger and single, then reconstruction may have been a more important issue.
Judy's two sisters, Margaret, 44 and Sara, 43, who both live in St George, Barbados, carry the breast cancer gene, too. Youngest sister Sara was diagnosed with breast cancer in 2002 (a year before Judy) and had a mastectomy on her right side.
Three years later, on advice from her doctor, Sara had her left breast removed and reconstructed with a saline implant in case the cancer returned. How did she feel to lose her other breast? "I accepted that it was done in the interests of my health," she says, and goes on to explain that, like Judy, she just wanted the cancer gone and that the surgery was her only option. "I had no choice. I wanted life more than a body part," she says.
In 2006, to balance out her shape, Sara decided to have her right side reconstructed with muscle and fat from her stomach, in a free versus pedicle tram flap procedure, commonly known as a ‘tummy flap' procedure. She is thrilled with her new breasts and has come a long way in the last six years.
Middle sister Margaret, who is married to Roger, with two teenage children, decided to be tested to see whether she carried the gene in 2006. She suspected it was more than likely as her two sisters carried it but she wanted to know for sure so that she could act quickly to minimise her risk of breast cancer.
"I felt a sense of relief knowing my situation and being able to act on it. My strong faith and my family behind me made it a lot easier," she explains. So after the positive test result, Margaret decided to have a bilateral mastectomy and immediate reconstruction. She began to prepare herself for her surgery and ensure she was as fit and healthy as possible to minimise her recovery time.
"Before the surgery I spent eight weeks preparing my upper body at the gym - and I think the fact that my upper body was strong helped a lot," she says.
The mastectomy and reconstruction took place at a private hospital and Margaret experienced an emotional rollercoaster as she began to accept her new breasts. "After the surgery I was very insecure about my body. The shape and size of my breasts were foreign to me, they were not ‘mine'. I think the biggest adjustment was not having any feeling in them as the nerve endings had been destroyed."
What does Judy think of Margaret's new breasts? "I saw Margaret six months after she had the reconstruction - her breasts were sitting right where they should be, pointing in the right direction. They looked beautiful!" And although Judy has chosen not to go for reconstruction, she can quite clearly see the benefits that the procedure would have for a lot of women, "I would never put anyone off reconstructing - but what I would say is deal with one issue first."
Two years on from her mastectomy and Margaret has no regrets. She is happy with her new breasts and doesn't look back. She is relieved she had the genetic testing, thrilled with her reconstruction (she went from a B cup to a C cup) and wouldn't hesitate to do it all over again. She will also consider having her ovaries removed as she nears menopausal age, as she has a high risk of contracting ovarian cancer. In terms of breast cancer, she believes taking preventative action by having a mastectomy is the right way to go. "It beats what my sisters had to go through and fortunately for me I could act before I got cancer - my sisters did not have that choice," she says.
The Surgeon's View
Charles Nduka, cosmetic surgeon at the Nuffield Hospital in Brighton and Consultant Plastic and Reconstructive Surgeon at the Queen Victoria Hospital Foundation NHS Trust, Sussex.
What's your view on immediate reconstruction following mastectomy?
All women due to undergo mastectomy should be considered for immediate reconstruction. There are, however, situations when it's less appropriate, for example, very advanced cancers. The main advantage of immediate reconstruction is that it allows the women to preserve more of her breast skin, and produces less scars and a more natural looking result.
The gold standard technique is the free DIEP flap which creates a breast using the woman's abdominal tissue - the so called ‘tummy tuck flap'. Its major advantage is that implants are avoided with their potential longterm issues and the breast feels and moves more naturally. Of course for larger women there is the added benefit of improving overall body contour.
Not all women feel psychologically or physically up to a six to eight hour operation which is understandable. In this situation, a good compromise is a ‘delayed-immediate' reconstruction where a skin sparing mastectomy is performed and an implant is placed, which is a relatively quick procedure. This preserves the breast skin and allows the women to recover enough for a DIEP or TRAM flap to be performed at her leisure.
Is it possible that prosthetic implants can hide breast cancer or make it trickier to detect?
Patients who have had breast cancer are closely followed up by the oncology team and where mammography is difficult or impossible, MRI screening is a sensitive tool for breast examination. Patients who are considering cosmetic breast implants sometimes worry about whether implants can hide a breast cancer, but the evidence suggests there is no overall risk compared with women without implants.
In what circumstances would flap surgery be more preferential to implants? Is it sometimes the case that one type of surgery is financially more viable than another?
Flap surgery is ideal for larger breasted women, those who have had (or will undergo) radiotherapy, and those who are concerned about possible future issues with implants such as leakage, capsular contracture and progressive asymmetry (due to droop of the normal breast). While flap surgery is more expensive in the short term, most patients do not need to see their plastic surgeon again after a year when the result has settled. The same is not the case with implants which are probably more expensive due to the requirement for longer follow-up and revisional surgery.
What's the best type of implant to use?
The best implant after mastectomy is one that is anatomically shaped, i.e. thinner at the top and fuller at the bottom, sometimes known as tear drop shaped. In practice, a silicone shell containing an expandable saline pocket is often used to stretch the skin and create a more natural droop. With saline implants, rippling or wrinkling of the implant shell may become visible in the cleavage area or near the armpit where the implant lies just beneath the skin. In these situations, a cohesive gel silicone implant will give a better result.
CSMUK
