Columbian Aira Flanagan’s decision five years ago to undergo a double mastectomy was easy, she candidly tells Verne Maree. As a child, she had lost her mother to breast cancer. She herself had just been diagnosed with cancer in one breast. And tests showed that she had the rare, defective gene that gave her an unusually high chance of it developing in the other.
Where are you from, and what brought you to Singapore?
I’m originally from Columbia; Flanagan is my Irish husband’s name. His business career brought us here three years ago, with our then-three-year-old daughter, Chloe. Now we’re about to relocate to Chicago. I don’t mind, but I’m a bit afraid of the cold!
Tell us about your family background.
There’s a strong history of cancer. Not only did my mother die of breast cancer when she was 33 and I was just six years old, but her two sisters both died of cancer before they’d turned 40.
What were the circumstances leading up to your breast cancer diagnosis?
Given my family history, I started having annual mammograms from the age of 24; I’d found a little lump that turned out to be benign. One day, when I was 43, I felt an ongoing burning sensation in my left breast.
It was June 2008. We had just moved to Dallas, Texas, and Chloe was not even a year old. A mammogram did not pick up anything amiss, but ultrasound found a small lump in the painful breast. My doctor did a biopsy, which sure enough was cancerous. Fortunately, the carcinoma was not yet invasive and did not seem to have spread.
What kind of surgery did you undergo?
I was referred to both a radiologist and an oncologist, who advised me to have the gene test. It was positive, confirming that I had the BRCA1 gene mutation, which put me at five times the normal risk of breast cancer and ten to 30 times the risk of ovarian cancer. I’d already made my mind up long before that to undergo a double mastectomy if the gene test was positive.
It’s a long operation, because a number of tests need to be performed during the process. They removed the nipple and areola and then scooped out all he breast tissue. They opened up both armpits, too, to check the lymph nodes. Once the checks had been completed, the plastic surgeon inserted the expanders, each partially filled with a little saline solution.
For seven months after that, I had to go in every two weeks for saline injections into the inserts, to expand them very slowly until they’d reached the desired cup size. It was most uncomfortable; the body takes a long time to recuperate from this sort of surgery.
You underwent chemotherapy at the same time, didn’t you?
Yes – I had four rounds during the latter part of 2008. I’d been advised that chemotherapy would make sure of killing off any stray cancer cells that might be in my body, so I could be 99-percent sure that the cancer would not return. I’d lose my hair and my eyebrows, of course, but hair grows back.
Having such a young baby kept me busy and helped me to stay positive. I would have my chemo treatment one day, and by the next day I’d be in the gym, wig and all, much to my mother-in-law’s dismay. Regular exercise helped me recover more quickly, both from the chemo and the ongoing reconstruction.
I like the Spanish expression agarrar el toro por los cuernos – meaning to grab the bull by the horns. I guess it goes back to losing my mother at the age of six; I had to grow up quickly and learn to be strong. Unlike her, I was lucky to be diagnosed at such an early stage and had medical options that enabled me to continue living.
How did your family and friends react?
I was lucky to have a mentor, the sister of a friend of my mother-in-law who’d had a mastectomy herself. It’s important to have help and I appreciate the support I’ve had from my husband and family, but I never wanted them to cry for me or pity me. I’m very aware that there are many people who have been afflicted by far worse things.
Have you completely recovered?
My hair and eyebrows are not nearly as thick and strong as they used to be, and having chemo and my ovaries removed at the age of 43 put me into early menopause. I go for annual checkups, and I’m fine.
The way I see it, my breasts do not define me as a woman. That said, I was living in Dallas at the time and was lucky to have one of the best doctors in the world.
In May this year, Hollywood actress Angelina Jolie revealed that she had undergone a prophylactic double mastectomy on finding out that carried the defective gene – even though she did not have cancer at the time. What do you think of her decision?
I think it’s very courageous of her to tell her story. We look at these beautiful celebrities in their perfect worlds and we think nothing can touch them, but she has reminded us that we’re all mortal and all equally vulnerable. The actress Christina Applegate, too, underwent the operation shortly after I did; her talking about it made me feel I was not alone.
Do you have a message for other women?
It’s important to remember that for 70 percent of breast cancer cases there is no family history of the disease. My advice is to regularly check your breasts from an early age, as we women know our own bodies best. If you find anything suspicious, immediately get it checked by a doctor.
Aira Flanagan’s story raises a lot of questions for us. Parkway Cancer Centre oncologist Dr Khoo Kei Siong, and general surgeon Dr YY Tan, who specialises in breast surgery, answer some of them.
Is the gene test available in Singapore?
No, it’s not. Myriad Genetics, Utah, holds the patent and so has the monopoly on testing the BRAC1 and BRCA2 genes. At this point, all samples have to be sent there for testing, and the test costs between $4,000 and $5,000.
Who should have the gene test?
Any patient with a strong family history of breast and or ovarian cancer warrants a discussion about testing for BRCA mutation, Dr YY Tan believes.
It may be worth considering, says Dr Khoo, if you’ve had more than one incidence of breast cancer in the family, and both were diagnosed under the age of 40; or if there is a history of cancers across generations involving breasts as well as ovaries. Male breast cancer in the family is another risk factor.
However, even when you narrow down the test criteria in this way, there is only a 10 to 20 percent overall likelihood of the gene test finding either of the mutations.
What do you think of Angelina’s and Aira’s decisions?
For someone like Aira, says Dr YY Tan, who carries the defective gene and was herself diagnosed with breast cancer in one breast, a therapeutic mastectomy for the cancer plus a preventive mastectomy on the breast was a reasonable option to reduce her long-term risk.
It’s a very individual decision, both doctors agree. “For Angelina,” says Dr Khoo, “being aware that her particular risk of breast cancer was close to 90 percent meant that options apart from mastectomy were quite limited. Her bilateral prophylactic mastectomy has reduced her risk to one percent or less.”
Hoping for prevention, you could just increase surveillance, using MRI, which is more suitable for younger breasts than mammograms are. Chemo-prevention in the form of medications such as Tamoxifen and Raloxifen can reduce the risk of breast cancer by about half, he adds. Like all drugs, though, they have associated side effects.
Not everyone with a family history will develop invasive breast cancer. How important are lifestyle factors in the development of breast cancer?
Dr YY Tan believes that lifestyle is fairly important, and is probably the reason we are seeing an increasing worldwide incidence of breast cancer. Lifestyle changes such as poor diet and lack of exercise, stress, the modernisation of society and environmental factors such as pollution and pesticides play a role; so does the fact that women are having babies later, having fewer babies and doing less breastfeeding.
“Anything in the world we live in that is different from the way our grandparents lived 80 years ago may be a contributory factor!”
According to Dr Khoo, risk factors include obesity, high intake of fat, drinking alcohol, having children later in life or not at all, taking HRT for more than five years after menopause, and – to a lesser extent – smoking. Exercise, on the other hand, reduces the risk of breast cancer in menopausal woman.
To reduce risk, follow a healthy diet that steers clear of red and processed meats; choose whole grains instead of refined grains; eat plenty of fruit and vegetables and control caloric intake to avoid weight gain. Women should drink no more than one alcoholic drink per day. Exercise regularly, for at least 30 minutes on five or more days of the week.
Frequent mammogram x-rays on young women are suspected of contributing to the risk of developing breast cancer. It also seems that those who carry the mutated BRCA1 gene are more vulnerable to this effect of x-rays. What’s more, mammograms are seen as a blunt tool that often fails to detect breast cancer. As a result, some women prefer to avoid mammograms and go for ultrasound instead. What is your opinion?
“Aira should not have been having annual mammograms from such a young age,” says Dr Khoo. “Such screening should start only at 40. For someone at high risk who should start to be screened earlier, we suggest MRI instead.”
Dr YY Tan concurs. A diagnostic mammogram may be done for a 30-something woman in whom breast cancer is suspected, but routine annual mammogram screening is usually not recommended in the 20s or 30s. MRI screening has a higher sensitivity than mammograms do for cancer detection in young women, who have denser breasts. Unfortunately,” she adds, “false positives can occur, and an MRI costs about 10 times more than a mammogram.”
Ultrasound is useful as an adjunct screening tool for women with dense breasts, she explains, but it does not completely replace the mammogram. “Precancerous changes such as micro-calcifications cannot be detected on ultrasound.”
Any special message for our readers?
Dr Khoo points out that the great majority of breast cancers are unrelated to heredity. “Hereditary breast cancer accounts for a tiny minority of only four percent of all breast cancers; and those related to the two mutations make up about two thirds of those.” And because of the implications for both the individual and the family,
anyone who goes for testing should first receive proper information and counselling, he adds.
“Remember that breast cancer is a very curable disease if diagnosed early,” says Dr YY Tan. “Examine their own breasts regularly and undergo the recommended mammogram and ultrasound screening. Follow a healthy lifestyle, eat and exercise well and stay happy!”
She would also like to reassure breast cancer survivors that in the absence of a BRCA mutation, the risk of developing a new cancer in the other breast is less than one percent per year. “While there is always anxiety about possible cancer in the other breast in the future, in reality the risk is relatively low.”
More facts about breast cancer
– A UK woman’s chance of developing invasive breast cancer before the age of 50 is 2%; by age 70 it’s 7.7%. A third of all breast cancers occur after 70, and your lifetime risk is 12%. It’s the same in the US.
– Men and women in equal numbers can carry a deleterious BRCA1 or BRCA2 gene mutation.
– With this BRCA1 mutation, you have a 50-60% chance of developing breast cancer and a 35-46% chance of ovarian cancer by the age of 70.
– With BRCA2, the chances are 40-57% and 13-23% respectively.
– Without screening or medical intervention, a typical 25-year-old woman has an 84% chance of surviving to the age of 70. For one who has the BRCA1 gene mutation, it’s a 53% chance; with the BRCA2 gene mutation, it’s 71%.
– BRCA1-related cancers appear on average two decades earlier than usual.
– BRCA2-related cancers are more likely to occur at or after menopause.
What is a mastectomy?
A mastectomy involves removal of the entire breast. If there is immediate reconstruction, then the skin can be preserved – and sometimes the nipple too, if the tumour is far enough away from the nipple. If there is no immediate reconstruction, then the excess skin and the nipple will have to be removed.
Nowadays it is standard treatment to perform immediate breast reconstruction together with the mastectomy. Plastic surgeons are now also able to perform immediate nipple reconstruction, too.