SUMAYYA EBRAHIM GYNAECOLOGIST PARKLANE CLINIC JOHANNESBURG The Angelina Jolie Example : Risk Reducing Surgery for Breast and Ovarian Cancer SUMAYYA EBRAHIM GYNAECOLOGIST PARKLANE CLINIC JOHANNESBURG

MAY 2013

STATISTICS SOUTH AFRICA NATIONAL CANCER REGISTRY Lifetime risk of ovarian cancer 1:82 Lifetime risk of breast cancer 1:29 (2004)

GENETIC CANCERS BRCA 1 and BRCA2 mutations: 5-10% breast cancers 10-15% ovarian cancers (white women in USA)

BRCA Tumour supressor gene Breast cancer susceptibility gene 1 (BRCA 1) Breast cancer susceptibility gene 2 (BRCA 2)

INCIDENCE OF BRCA BRCA 1 general population 1:500-1:800 BRCA 2 lower Ashkanazi Jewish Descent 1:40

CANCER RISKS WITH BRCA Increased cancer risk Breast cancer risk 5x higher Ovarian cancer risk 3-5 x higher

OPTIONS WITH BRCA SURVEILLANCE RISK AVOIDANCE PROPHYLACTIC SURGERY

SURVEILLANCE BREAST CANCER:self examination mammograms MRI OVARIAN CANCER:clinical examinations vaginal ultrasound Ca125 level

RISK AVOIDANCE Reduction in body fat Reduction in alcohol intake Reduced dietary fat Increase physical activity

PROPYHLACTIC SURGERY BILATERAL PROPHYLACTIC MASTECTOMY BILATERAL PROPHYLACTIC SALPINGO- OOPHORECTOMY

PROPHYLACTIC BILATERAL MASTECTOMY Complete removal of both breasts Including nipples:TOTAL MASTECTOMY Nipple conservation:NIPPLE SPARING MASTECTOMY

TOTAL BILATERAL MASTECTOMY WITHOUT RECONSTRUCTION

TOTAL BILATERAL MASTECTOMY WITH RECONSTRUCTION IN PROGRESS

TOTAL BILATERAL MASTECTOMY WITH COMPLETED RECONSTRUCTION

CANDIDATES FOR P.MASTECTOMY Known BRCA1 and BRCA2 mutations Strong family history without BRCA mutations Lobular carcinoma in situ(LCIS)+family history Radiation to chest wall before 30 years of age Cancer in one breast

BENEFITS OF P. MASTECTOMY BRCA1 BRCA2 MUTATIONS Expected risk reduction of 95% STRONG FAMILY HISTORY Expected risk reduction of 90%

DRAWBACKS OF P.MASTECTOMY Irreversible Expensive :multiple operations time consuming days off work Procedure related complications:infection bleeding Psychological:change in body image

BILATERAL PROPHYLACTIC SALPINGO-OOPHORECTOMY (BSO) Removing both the ovaries and fallopian tubes

TECHNIQUES FOR BSO

CANDIDATES FOR BSO High risk women BRCA 1 and BRCA 2 mutations Premenopausal Older than 35 Completed families

BENEFITS OF BSO IN HIGH RISK WOMEN Expected risk reduction of ovarian cancer 90% Expected risk reduction of breast cancer 50%

DRAWBACKS OF BSO Permanent and irreversible Surgical complications:infection ; haemorrhage ;intestinal obstruction Immediate surgically induced menopause discomforts osteoporosis heart disease memory loss and dementia

BSO AT WHAT COST ? WITH NO HRT Higher rate of premature death,cancer, heart disease and neurological disease HRT?????????

CONCLUSION RISK REDUCING SURGERY FOR ALL?