Surgery for prevention

Ksenia Skrypnik, "Mednovosti"

In 2013, the world was surrounded by news that could not go unnoticed. American actress Angelina Jolie had a preventive mastectomy. She decided to have surgery to remove both mammary glands (and in 2015 she had her fallopian tubes and ovaries removed) to reduce the risk of cancer.

The actress turned out to be a carrier of one of the forms of the BRCA1 gene associated with an increased risk of developing breast and ovarian cancer. Doctors determined that the probability of contracting these forms of cancer for her was 87% and 50%, respectively. The operation allowed to reduce these risks by up to 5%.

Jolie's act became a real event that was discussed by almost everyone: the actress's decision seemed strange and surprising to some, and it prompted others to undergo a screening examination and also decide on such an operation. Scientists started talking about the "Angelina effect" – after the actress announced her operation, the number of preventive mastectomies in different countries began to increase.

Such operations, however, are not limited to mastectomy. We talked with Vadim Gushchin, director of the Department of Surgical Oncology at Mercy Medical Center in Baltimore, USA, about what preventive operations are, how to prepare a patient for them and prepare a doctor for them. 

– And what other preventive operations are performed by doctors?

Preventive surgery is a rather narrow area in oncology. The most common of these operations is preventive mastectomy. It is also made in Russia. In addition, cases of removal of the thyroid gland, colon are not uncommon.

It is not difficult to perform such an operation – it is easier to remove a healthy organ than a cancerous tumor and tissues affected by metastases. The operation itself is preceded by a long preparation and coordinated work of geneticists and clinicians. In most cases, a family history is collected first – we find out what forms of cancer family members suffered from and what caused these tumors.

For example, mutations of the RET gene are associated with an increased risk of medullary thyroid cancer, a very aggressive form of cancer. In some cases, even children become patients – the study of family history suggests that members of a particular family are carriers of a dangerous mutation, and further examinations confirm this version.

If this form of cancer has already been detected in someone's family, then this patient is first tested for genetic testing, and only then other relatives are tested, if they agree to such a study, of course.  For those who are found to have a mutation, we can offer preventive surgery.

Another case is an increased risk of colorectal cancer associated with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis. Under certain conditions, colon removal is recommended for such patients.

 Recently I had to have a gastrectomy operation – removal of the stomach. My patient was a woman whose mother died of aggressive stomach cancer at the age of fifty. She was treated in our department: in addition to stomach cancer, she was diagnosed with lobular breast cancer. This combination gave us the idea that the patient has diffuse stomach cancer. Not so long ago, it was shown that this form of cancer is associated with a mutation of the CDH1 gene encoding the cadherin 1 protein. Cadherins are cell adhesion proteins, mutations affecting them can lead to disruption of communication between cells, which occurs in hereditary diffuse cancer.

A genetic examination revealed the presence of a mutation in my patient and her sister, as well as in their mother.  An aggressive form of cancer occurs in 80% of carriers of the CDH1 mutation. The patient had to choose between two options: preventive gastric removal or regular screenings aimed at detecting the disease at an early stage (unfortunately, "detecting cancer at an early stage" in this case and many others does not lead to preventing death from a tumor). As a result, both sisters chose preventive gastrectomy – the older sister underwent this operation two years earlier than my patient. Most likely, this positive example also helped in making a decision. Already on the fifth day after the operation, the patient was discharged home, and a month after discharge she was able to return to normal life. Of course, she had to adapt to life without a stomach, but now the risk of developing cancer has significantly decreased.

– Is it difficult for a patient to decide on such operations?

It's not easy to make a decision. We, as doctors, have no right to persuade and insist on surgery. In our conversations with patients, we can only talk about the possible risks associated with both the patient's disagreement with the operation and what awaits him if he agrees to such an operation.

Even at high risks, the tumor may not develop, but when it occurs, the patient may be waiting for a long and unpleasant treatment – chemotherapy, radiation therapy, complex surgery, which, unfortunately, is not always effective. It is worth remembering that after surgery, the risk of cancer does not disappear completely, but only decreases, although quite significantly.

Often we offer our patients to meet with those who have already decided on such an operation. It takes quite a long time to wait for a decision to be made, but it is impossible to insist, a person must agree to the operation independently.

– Is it probably not easy to talk about this with a patient?

Indeed, it's not that easy. In order to talk with a patient, and especially with a cancer patient, a trusting long-term relationship must be established between a doctor and a patient. The doctor should be on the same level with the patient: venerable doctors during a serious conversation, for example, it is better to take off the robe, and young doctors, on the contrary, put it on, thus adding solidity to themselves.  But in the department of pediatric oncology, doctors go without dressing gowns, so it's easier for them to earn the trust and sympathy of young patients. It is better to try to conduct any conversations on an equal footing, this is the approach that patients like the most.

– Is it a special gift or can you learn it?

How to conduct an appointment, talk to a patient, report bad news – all this can be learned. I am currently teaching this and many other things to a small group of Russian oncology residents. We started training in September 2015 and every week on Saturdays we hold joint video conferences via Skype.

We're not just talking about medical ethics. I teach them the basics of modern oncology, including the concept of cancer prevention, the basics of a scientific approach in oncology.

These are not lectures, but rather seminars. We discuss and analyze scientific articles and cases from medical practice, prepare for independent presentations at scientific conferences. Such training is carried out within the framework of a project implemented by the Cancer Prevention Foundation, which has launched a program aimed at supporting vocational education. 

Earlier, the Foundation announced the launch of the SCREEN program, created for the prevention and early diagnosis of cancer. Anyone can fill out a questionnaire posted on the Cancer Prevention Foundation's website and receive individual recommendations regarding the necessary examinations. The system offers to sign up for these examinations, or will remind you about them later. The full range of them can be completed only in Moscow and St. Petersburg, but the developers plan to connect regional clinics as well.

Portal "Eternal youth" http://vechnayamolodost.ru  21.07.2016