Breast Cancer Survivor Christina Applegate Opts for Preventive Double Mastectomy and Breast Reconstructive Surgery
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Reviewed By Louise Chang, MD
Applegate, 36, star of the ABC comedy Samantha Who?, announced her breast cancer diagnosis earlier this month. Yesterday, she told ABC's Good Morning America that she is now "absolutely, 100% clean and clear" of cancer.
Before getting her preventive (prophylactic) double mastectomy three and half weeks ago, Applegate had two lumpectomies — and only had cancer in one breast, according to Good Morning America — and took a gene test that showed that she had the BRCA1 gene mutation, which makes breast cancer and ovarian cancer more likely.
Applegate called her mastectomy decision "tough" but the "most logical" possibility for her. She said she based her choice on her family history — her mother has had breast cancer and cervical cancer — and her BRCA1 gene.
Is Applegate's approach to breast cancer one that would work for other breast cancer patients? And what will the reconstruction process — for Applegate and for other women — be like?
WebMD talked with four doctors — and with a breast cancer survivor who made some of the same choices that Applegate did — about preventive mastectomy and breast reconstructive surgery. None of the doctors who talked to WebMD are treating Applegate.
Did Applegate make a good choice?
"I think she did the absolute right thing, and she did it the right way," says Jay Brooks, MD, FACP, chief of hematology/oncology and chief of staff at the Ochsner Health System in Baton Rouge, La.
"She underwent lumpectomy and then, when she got the information back from the genetic testing, she was able to have a little time to discern what this all meant and then she went forward to have the prophylactic mastectomies, which are clearly the best treatment to reduce her risk of ever developing breast cancer [again] by at least 90%," says Brooks.
"I think that's a very reasonable approach," says Brooks. "It may not be right for every patient, but I think especially if you have this genetic mutation — it's such a highly active mutation in terms of increasing the risk of breast cancer — that it's certainly something that I would recommend to one of my family members or to my patients, and I do," says Brooks, noting that only about 5% to 7% of breast cancer patients have cases similar to Applegate's.
"Because her risk of an additional breast cancer is extremely high, in the range of one in two, why take a chance?" asks Eli Avisar, MD, breast cancer surgeon at the Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine.
Gisella Alvarez, RNC, is a nurse at Mercy Medical Center. Two years ago, at age 44, Alvarez learned she had stage I breast cancer in one breast. She decided to have both breasts removed and get breast reconstruction. Her case wasn't exactly like Applegate's — Alvarez had an elderly aunt who had had breast cancer but she hadn't had the BRCA gene test — but she took a similar approach.
Alvarez says Applegate's decision was "brave" and "smart because life is too short. It's not worth living your life worrying every six months when you have to go back for tests and more tests — and hoping that it's not going to come back. With this way, you really increase your chances of not having to worry about it again and live your life."
Does double mastectomy totally eliminate her risk?
Almost, but not quite; there's an estimated 5% chance of breast cancer after such a procedure, notes Neil Friedman, MD, FACS, medical director of the Hoffberger Breast Center at Mercy Medical Center in Baltimore.
He explains that there's no clear line where breast tissue ends.
"When you're in the operating room, it's not like you can look and say, 'All that yellow tissue is breast tissue and all that white tissue is fat.' So you try and take all the tissue out that you can, but you can leave isolated breast cells underneath the skin. Everybody does; there's not a surgeon in the world that can do that and remove all of the cells. That's why there is a small risk of having a breast cancer develop in one of those cells — pretty uncommon, but it can happen," says Friedman.
Friedman says that immediate reconstruction — starting the process at the time of the mastectomy — "is something that should be offered to all patients."
"I offer it to all of my patients and if I think there's a reason why they shouldn't get it from a medical perspective, then I [explain why] I think it's advisable to delay the reconstruction. But they should at least have that conversation with their surgeons," says Friedman, adding that breast reconstruction is not an insurance issue, because it "must be paid for by federal law," regardless of the patient's age.
What about the emotional aspect of the decision?
"It is a difficult decision and an emotional decision, and it is not that simple to decide to lose your breast," says Avisar.
Alvarez says she took her time before choosing preventive double mastectomy. For her, breasts were "such a part of being a woman, so there [were] a lot of emotional factors" to consider.
"Little by little, I just went through the options," she says. One by one, she ruled out her other choices and felt that after mastectomy, she would "be able to live my life peacefully and life goes on."
Alvarez also said it helped that she works on a floor of Mercy Medical Center where women recover from mastectomy and breast reconstruction, so she knew what to expect. She also had seen women be upset by their appearance immediately after mastectomy.
"They just don't want to look at themselves ... it's an extremely difficult experience," says Alvarez. "I never really had a problem with that only because I knew what that was going to be like."
What's involved in breast reconstruction?
The first step is creating the breast or breasts, which can be done in two ways:
- Option No. 1: Transplant your own fat [autologous tissue] from the belly or elsewhere in the body and implant it where the breasts were.
- Option No. 2: Get saline or silicone implants.
Which option to pick? "Oftentimes, it comes down to a woman's preference," says Brendan Collins, MD, plastic and reconstructive surgeon at Mercy Medical Center in Baltimore.
Each approach has pros and cons.
With autologous tissue, you "don't have to worry about potential problems related to the implant," such as eventually needing to replace it, says Collins. But it's a longer surgery and recovery process, since two parts of your body — your breast area and the place where the fat came from — need to heal. And very lean women may not have enough fat to transplant as breasts.
Getting artificial implants for breast reconstruction doesn't happen right away. First, surgeons typically insert tissue expanders at the time of mastectomy. The tissue expanders "are like a salt water balloon that's put underneath the muscle," says Friedman.
Doctors inflate those tissue expanders gradually to stretch the skin and make room for a permanent salt water or silicone implant. Doing that is an in-office procedure in which doctors use a syringe to inject more fluid into the tissue expander, Avisar explains.
That goes on for several months, until the breast reaches the desired size, and then surgery is done to replace the expanders with permanent implants.
After that, surgeons can create an artificial nipple by raising some of the new breast's tissue, and then tattoo on coloring to simulate the areola (the dark area around the nipple). The new breast may also need some cosmetic adjustments.
How long does breast reconstruction take?
"Give it about a year," says Collins.
For Alvarez, her process took a year and three months. "You have to be so patient," she says. With all reconstructions, "it takes a long time until you finally have your final result."
She kept a photographic journal of her progress and shared it with her colleagues. "I just made it like an educational opportunity ... We never know what the patients go through when they leave."
Does it hurt?
Alvarez says she had pain after the mastectomy, but "the other processes were not as uncomfortable."
After the mastectomy, Alvarez says she was "uncomfortable for about a week and a half" and did occupational therapy exercises to get her range of motion back.
What kind of reconstruction is Applegate getting?
She hasn't said. But Good Morning America reports that her reconstruction will take eight months.
"The majority of patients ... don't go the whole 9 yards," says Avisar. "Most of them do the first step. Many of them never come back to have the nipple and areola reconstructed. They are just tired and they have had enough."
Applegate may be different. "She is an actress and may be more aware of her body," says Avisar.
Are patients satisfied with the reconstructed breast?
It depends on their expectations and the cosmetic results.
"If a patient is expecting to be happy because she's alive, she's going to be happier than the patient who puts, as the most important thing, her appearance — and may be disappointed because what she sees is not what she pictured," says Avisar.
Reconstruction is an alternative to wearing a prosthetic breast, but it is "totally different" from getting breast implants for cosmetic reasons because it's not a real breast.
After reconstruction, "we do expect you to be able, with clothing on, to look normal without having to have prostheses," says Avisar. "But if the expectation is for the breast to feel normal and to look absolutely normal in front of the mirror without any cover on it, this is probably not going to be the case."
Alvarez says she is "very happy with the results" and shares her story with patients, since she works on a floor of Mercy Medical Center where mastectomy and breast reconstruction patients recover.
Her advice: Talk to your surgeons. "I was very concerned about my cleavage. I talked to my surgeons and made sure that I kept it." She says she wound up with "fabulous cleavage" and a "great set of new, fake breasts."
SOURCES: Good Morning America. Christina Applegate's Breast Cancer: FAQ. Jay Brooks, MD, FACP, chief of hematology/oncology and chief of staff, Ochsner Health System, Baton Rouge, La. Neil Friedman, MD, FACS, medical director, Hoffberger Breast Center at Mercy Medical Center, Baltimore. Eli Avisar, MD, breast cancer surgeon, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine. Brendan Collins, MD, plastic and reconstructive surgeon, Mercy Medical Center, Baltimore. Gisella Alvarez, RNC, Mercy Medical Center, Baltimore.
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