For women, this can be the most difficult decision in their cancer journey since femininity and a fundamental sense of identity are tied up in it, says a breast cancer surgeon. “Will I need to remove my breast?” As a breast cancer surgeon, I get asked this question all the time. The diagnosis of breast cancer evokes anxiety in women, not just because it is a cancer, but also because of the possibility of surgical removal of the breast. Breast cancer is the most common cancer among women in Singapore with more than 2,000 women are newly diagnosed every year. Other than surgery, breast cancer may also require additional treatments such as chemotherapy and endocrine therapy, both of which can result in short- and long-term changes in a woman’s life. Research has shown that the psychosocial impact of breast cancer occurs not just at diagnosis, but also during treatment and survivorship. Women may experience distress associated with fatigue, mood, sexual and reproductive issues, self-image, spiritual challenges, relationships with others and fears of recurrence. Yet in clinical practice, how a woman copes with a breast cancer diagnosis may vary widely, depending on her age, family situation, attitude, and life priorities. WIFE, MOTHER, WOMAN *Anna was diagnosed with breast cancer five years ago at 41. She could have opted for a smaller surgery to keep the breast. Instead, she chose to have her breast removed. She also nonchalantly declined breast reconstruction to minimise surgery time and complications. She told me: “My mother had breast cancer too and I watched her suffer through the treatment. I want to come out of this better and stronger than she did.” Her priority was no-fuss surgery, swift recovery and quickly moving on to chemotherapy and radiotherapy, minimising long-term relapse risk. Then there is *Celine who was 77 years old when a breast biopsy confirmed cancer. As the changes were extensive, she required a mastectomy. Despite the risks at her age, she insisted on breast reconstruction. “Doctor, I won’t feel complete without the breast. Please arrange for me to have reconstruction,” she told me. Fortunately, she was found to be surgically fit for her age and she successfully underwent mastectomy and implant reconstruction. These two cases show there is no one size fits all approach. Women play many roles in life – as a wife, a mother and a daughter. These roles strongly influence their attitudes towards breast cancer treatment. Some mothers of young children are driven to treat the breast cancer aggressively, to survive the cancer so they may continue their parenting role. Others fear the treatment will take them away from the family and in contrast may choose less intensive options. Some opt to relegate their caregiver role completely to other family members. Older women may decline treatment so avoid being a burden to their families. A SYMBOL OF FEMININITY The anatomical function of the breast is for lactation, allowing mothers to nurse their babies. Beyond this, the breast also symbolises femininity and is a major part of constituting a woman’s body image. This is why removal of the breast has a deep impact on a woman’s body image, taking a physical and psychological toll on patients. Ironically, reconstruction may not ease these feelings. Studies in the early 2000s showed younger women receiving mastectomy and reconstruction for breast cancer reported a more negative body image than those receiving breast conserving surgery, immediately following treatment, but this improved with longer duration from treatment. Other than surgery, other cancer treatments may also impact body image. Chemotherapy and endocrine treatment often result in hair loss, weight gain and the abrupt onset of menopausal symptoms such as hot flushes, vaginal dryness, decreased libido and reduced sexual functioning. These changes may cause psychological distress in both the breast cancer patient as well as her partner, potentially impacting on the emotional support that is critical in relationships. RECONSTRUCTION SURGERY Breast reconstruction plays a major role in contributing to the acceptance of mastectomy by women diagnosed with breast cancer. Immediate breast reconstruction is when the reconstruction surgery is performed at the same sitting as the mastectomy, hence the patient wakes up from surgery with minimal perception of losing the breast. This can be done using breast implants or autologous tissue from the patient’s own body tissue such as tissue from the tummy, thigh or back. In our Asian culture, women generally favour autologous tissue reconstruction over implant reconstruction, although other factors such as the patient’s physical make up may also come into play. Breast reconstruction is not without its risks, as the surgery will be longer and often more complex and with slightly higher risk of surgical complications. However, with proper patient selection and balance of risks and benefits, mastectomy with immediate breast reconstruction has been found to have fairly high levels of satisfaction in quality-of-life scores in the long term. THE ANGELINA JOLIE EFFECT I first met *Joan six months ago. She is 42 with a daughter in her early teens who is very attached to her. When she was diagnosed, she was adamant at removing both breasts even though the cancer was only confirmed on one side. In her own quiet but determined manner she told me: “I want to do everything to reduce my risk in the long run. I want to make sure I will always be there for my daughter.” In the last 20 years of clinical practice, I have witnessed a paradigm shift in women’s attitudes towards mastectomy. Conventionally, the breast is preserved whenever possible, especially if the cancer is localised. In recent years, more women are open to undergoing mastectomy even when breast conservation can be safely undertaken. I believe one of the most important reasons is due to the Angelina Jolie effect. Angelina Jolie was a well-known actress and celebrity, who in 2013 pronounced to the world that she had undergone bilateral mastectomy with implant reconstruction after discovering she possessed a BRCA gene mutation, which placed her at an inordinately high lifetime risk of breast cancer. It accelerated a movement in the USA where women made proactive decisions to be in control of their own destiny. In the last decade, there has been an increasing trend in women opting for bilateral mastectomy when the cancer is confined to only one breast. Reasons cited include fear of cancer recurrence, family history of cancer, stress surrounding follow up and improved breast reconstruction outcomes. Ironically, it has been suggested that in these women, bilateral mastectomy may even have psychological benefits. *Joan eventually did go ahead with bilateral mastectomy and reconstruction. Further laboratory testing subsequently discovered cancer in the other breast as well, which likely would have manifested some years later. So choosing bilateral mastectomy was the right choice for her and her family. For most women however, mastectomy can be a difficult decision as it still invokes an image of disfigurement and loss of femininity, despite significant advances in breast reconstruction techniques. Efforts in multi-disciplinary breast cancer care continue to focus on the psycho-social needs of this group of women. As a surgeon I hope every woman diagnosed with breast cancer will have access to adequate information and support in making the best decision for themselves, whether it is a mastectomy or breast conservation. We can’t make breast cancer go away, but we can make the treatment more acceptable and we can empower women to make the best choices suited to them. *Pseudonyms were used in this commentary. Article contributed and reviewed by Dr Tan Yah Yuen, Senior Consultant and Breast Surgeon at Solis Breast Care & Surgery Centre. Article first published on Channel News Asia: https://www.channelnewsasia.com/commentary/breast-cancer-women-health-breast-removal-reconstruction-2405711