Like Angelina Jolie

In St. Petersburg, they began to remove the breast when there is no cancer in it yet

Irina Baglikova, Fontanka.Roo

If a mother, grandmother and other relatives die of cancer, a woman has a high risk of developing the same disease. She goes to the geneticists, takes an analysis and finds out that she has become the heiress of a family mutation. When this happened to Angelina Jolie, she removed her breasts (then her ovaries) and told the whole world about it. A lot of people who wanted to do such an operation immediately appeared. They beat the thresholds of medical institutions with a request to do a preventive mastectomy — this is what the removal of mammary glands is called in medical language, when there is no diagnosis of "cancer" yet. But they were refused: such operations are prohibited in Russia. Now it can be done in St. Petersburg. Moreover, if cancer is found in one breast, the second one will be removed at the expense of the compulsory medical insurance system (CHI). Under what conditions is this possible and whether it is necessary to rush for such an operation, Fontanka asked Professor, MD, head of the surgical department of breast tumors Pyotr Krivorotko, NMIC of Oncology named after him. Petrova.

— Pyotr Vladimirovich, five years have passed since Angelina Jolie removed everything she could due to the fact that her cancer risk was more than 80% due to BRCA I and BRCA II mutations. And nothing — we still see a beautiful woman, all the forms are in place, she continues to work. Why is such an operation ambiguously treated in Russia?

— Don't try on Jolie's story. We see in magazines, movies and the Internet her beautiful — "glossy". But we don't know how she actually underwent the operation, how long it all took to heal, how many months the reconstruction lasted. And it can, with a certain anatomy, stretch into 2-3 operations, each of which is under anesthesia. All this does not add health.

Doctors do not have a consensus about such operations, because if a woman has a dangerous mutation, this does not mean that a tumor will certainly arise, although the probability of its occurrence is very high. Imagine that all the women in the world live up to 80 years old and there is a group with mutations among them. According to various data, in this group, by the age of 80, 30-70% will develop breast cancer — the probability of its occurrence is influenced by family history (whether women in the genus were sick — mother, grandmother, aunt) and a subspecies of mutation. But cancer may not happen — you may not live to see it, but you can live to a very old age without your cancer. Therefore, until now, for Russian women who found out about their oncological status, there was only one option — not to do any surgery, but to be constantly monitored: to do mammography, MRI, so as not to miss the tumor at an early stage. And when she appeared, it's another matter: we treat her, and at a certain stage the removal of the second breast is being discussed — doctors call it contralateral, this is called preventive mastectomy. At the NMIC of Oncology named after Petrov has already done about 50 such operations, since September they have been carried out at the expense of the CHI. There was no doubt in the medical community here: today it is known that every fifth of hundreds of women operated on for a tumor in one breast with BRCA I and BRCA II gene mutations will develop cancer in the second. And all the efforts of oncologists to treat the first tumor do not protect it in any way.

— Until now, if there was no diagnosis of "cancer", the clinic had no right to remove the mammary glands, even if mutations were detected — as if there were no indications for surgery. But now you can do it in your center.

— There were no clinical recommendations for performing such operations. As soon as there was a reservation that preventive mastectomy is allowed in a certain category of women, they became possible. Scientific Council of the NMIC of Oncology named after Petrova decided to perform a radical removal of the mammary glands in women without a diagnosis of cancer, but with mutations. The work approved by the scientific council is coordinated at all levels, it is, in fact, scientific and clinical.

Preventive mastectomy is done very recently, so there are no large studies that would give an unambiguous answer: yes, such operations are needed because they save from the development of cancer. It will take 20 or even 30 years for us to say that cancer has really been prevented. The study of any preventive method is carried out for a very long time. But at the same time, the medical literature describes cases when, after preventive mastectomy, women developed breast cancer (that is, it was a diagnosis, and not the tumor itself), and distant changes were detected from the breast — metastases. So, this is not a 100% way to protect yourself from the disease.

And the question of financing remains open. Treatment of patients with oncological diseases is paid either through the CHI system or through the VMP program. Preventive mastectomy of the mammary glands without a diagnosis of "cancer" is not yet included in any system of budget financing. So, it is carried out at the expense of the patient.

— Will preventive mastectomy ever be included in the budget funding? Why in Russia does the state not want to participate in it, if these are life-saving operations?

— Today hardly anyone will say whether the state will finance them. Because even the world medical community has not yet come to a consensus: is it necessary to do this? In some countries, preventive mastectomy is recognized as cancer prevention, in some of them, for example in the USA, it is done even without mutations — if there are cases of cancer in women in the family. In the Scandinavian countries, such prevention is very restrained, they do not use it at all. That is, this is a question that the medical service of a particular country answers itself, and the willingness of the state to participate in its resolution also depends on its answer.

— But it is already known that there are many who want to do such an operation: after Jolie's revelations, women almost massively did genetic research for mutations. And now many people know whether they exist or not.

— That's why I am against women prescribing genetic testing for hereditary mutations to themselves. Imagine a healthy woman finds out that she has this mutation. How will she take it? It can become such a stress for her that other serious conditions will arise, although there is no cancer yet and it is not known whether there will be.

She decides on a preventive mastectomy. Yes, desire is taken into account in the clinic, but it is not decisive. To do or not to do it — the council decides.

— If a woman wants an operation "like Jolie's", what should she do?

— First of all, think about whether there were women in the family who suffered from breast tumors, both on the maternal and paternal side. And consult a doctor who will recommend or not recommend a genetic analysis. At the same time, only a mutation is an indication for surgery — a family history is important, but without it it is an insufficient argument: if women were ill in the family and there is a mutation, then the prognosis for the manifestation of the disease is higher.

The doctor will ask if the woman wants to know about her genetic status if she has not given birth yet. She will explain that, despite the family history with two cases of cancer in her mother and grandmother, it is not a fact that the mutation will be revealed in her. In fact, not every woman in life, knowing that her aunt, mother, grandmother died of breast cancer, is ready to do this analysis. Many prefer not to know. Because otherwise it is necessary to do something with the knowledge gained (some do not do this analysis even with cancer).

— And if a woman performs a study, mutations responsible for the development of the tumor are detected, and she insists on surgery?

— There are many such mutations, and only BRCA I, BRCA II or both are clinically significant for performing radical surgery. If they are detected, the oncologist prescribes a full examination to detect or exclude breast cancer and sends the patient to geneticists to confirm the mutation. This will be followed by a consultation with a psychologist, and the next visit will be to a surgeon who will determine what surgical tactics are possible in each case: women are all different (weight, height, breast shape), he will also offer a technique for breast reconstruction.

At the same time, it is not necessary to compare mastectomy and breast reconstruction with operations performed by plastic surgeons. Our patients have a higher risk of complications, and the reconstruction is different.

And only after that, a consultation is going to be held: if experts agree that such an operation is shown to the patient and its benefits exceed the risk, then it will be done.

— What is the difference between breast reconstruction in your preventive surgery and the one used in the beauty industry?

— Preventive mastectomy is the complete removal of glands, muscles and lymph nodes. Only the skin sac, halos and nipple remain, there is nothing inside. Then a visual copy of the breast is restored — tactile sensitivity is impaired, but the woman remains with the forms of the mammary glands, and no one from the outside will understand that this is an artificially created mammary gland.

Aesthetic surgery changes the shape of the remaining breast, everything remains in place there.

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