Inside the 'Angelina Jolie effect' on breast reconstruction

Five years ago, Ms. Angelina Jolie elected to proceed with prophylactic double mastectomy after undergoing genetic screening and learning that she had a significantly elevated risk of developing breast cancer due to mutation of the BRCA1 gene. As a member of her surgical team, I was deeply moved by her courage and benevolence as Ms. Jolie shared with the world her journey through mastectomy, breast reconstruction and recovery.

Today, her story continues to inspire increasing numbers of high-risk women to undergo genetic screening. A greater number of women are now aware of the concept of preventative mastectomy and reconstruction. The media has dubbed this the "Angelina Jolie effect." To me, it is an ongoing source of inspiration and an example of how one woman has made such a tremendously positive impact upon the lives of others.

I have personally seen women whose lives were likely saved as a result of the public awareness that has resulted from the "Angelina Jolie effect."

During the past five years, breast cancer risk assessment has continued to evolve. Today we understand that BRCA mutations are only two of many mutations that significantly elevate breast cancer risk. Multi-gene panels now assess for a variety of mutations – including those affecting the CHEK2, PALB2, PTEN and TP53 genes, as well as many others. Identification of these gene mutations help to assess breast cancer risk during a woman's lifetime.

We now recognize a number of factors in one's personal and family history that might make genetic testing advisable. These include:

• Personal history of breast cancer, including bilateral breast cancer or diagnosis of triple negative breast cancer by age 60
• Personal history of ovarian cancer
• Family history of breast cancer before age 50 in two or more close relatives, including a mother, sister or daughter
• Close relatives of Eastern European Jewish ancestry who have a history of breast, ovarian or pancreatic cancer
• A close male relative with breast cancer

Breast cancer risk drops by approximately 90% among women who undergo prophylactic mastectomy. However, it is important to consider both the major and very personal nature of this decision. Undergoing a preventative mastectomy isn't right for every high-risk woman. Factors such as her estimated lifetime breast cancer risk, her willingness to tolerate that risk and her overall health must be considered.

Once the decision to undergo prophylactic mastectomy is made, the reconstructive options must be considered. As a plastic surgeon, I believe that it is very important to address with the patient the approaches that include the use of implants, as well as one's own tissues, to create the new breast.

Each patient is unique, and a personalized plan must be developed. In order to arrive at this plan, patient preferences, body type, lifestyle and overall health should all be taken into account.

During the process, it is essential that every patient take the time to develop a support team in which she is comfortable and confident. This team may include both general and plastic surgeons, medical and radiation oncologists, an internist, a geneticist and others. While the patient is the captain of her team, it is the privilege of each member of her team to strongly stand with her in helping to minimize long-term risk, maintain or achieve good health and restore wholeness.