Long Term Surveillance...Yes or No

This past week, I was fortunate enough to be asked to sit down for an interview and discuss BRCA as an expat.  One of the questions I was asked focused on the choices out there for women who find out they are BRCA+.  The one I always discuss, is the preventive prophylactic mastectomy, because, well, I had one and that was the topic everyone was curious about!  I didn't focus as much on the 10 years I spent doing surveillance due to having babies and being an expat.  But I feel that needs just as much discussion these days, because there are a lot of women out there who want nothing to do with surgery...just yet.

I look back, and I think about how crazy it is that I went through all this testing and getting my BRCA+ results before the Angelina Jolie Effect.  I had nothing to read online, no one to guide me and certainly no one to see photos of who had had a mastectomy and direct to implant surgery.  What I did have was a great team of doctors and a genetic counselor at Huntsman Cancer Institute in Utah, who were able to talk to me about my options at the time.  

Because I had just had a baby when I got my results, and I fell pregnant again, it was recommended to delay any surgeries for a while, and because I was breast feeding, even my mammograms and MRIs would be delayed.  That was the hardest part for me.  I knew for sure that I was BRCA+, but I still couldn't do anything about it.  I honestly would have had the surgery that day if I could have.  I was on self breast exam surveillance mode, and as soon as I could, I'd begin alternating MRIs and mammograms every six months.

Photo from Pixaby

I finally had my first mammogram in 2007, 2 years after learning I was BRCA+.  That was a long time to keep wondering, will I get cancer before I try to prevent it?  I was done breastfeeding my second child and I hadn't yet fallen pregnant with my third.  I held my breath before, during and after as I waited for results.  Luckily, it was negative.  After my third child was born and I was done breastfeeding, I had my first MRI, in 2009.  I hated every minute of it, and wished more than anything that I would never have to have another one again.  That began my surveillance, on a regular six month cycle, for the next six years.  Why did it take me six more years to finally have surgery?  Because we decided to pick up the family and move to the United Arab Emirates for a teaching position in 2010.

So, there we were, plopping down in the middle of the desert, and the first task I had was to find a new medical team, let alone, how to get a mammogram or MRI under my new, foreign insurance.  It took A LOT of talking, A LOT of doctors offices, and A LOT of panic.  I was an anomaly.  Doctors in the Middle East didn't have much experience with BRCA in 2010.  They honestly didn't know what to do with me.  

Thankfully, persistence paid off, as I found Tawam Hospital in the Emirate of Al Ain, a partner of Johns Hopkins.  Finally, people who knew what I needed.  They set me up on my six month schedule of MRIs and mammograms, and actually told me NOT to have reconstruction surgery in the UAE, as they just weren't proficient in it yet.  I couldn't go back to the States for it, due to insurance, so surveillance it was.  I continued my six month routine, holding my breath before, during and after every scan, developing scanxiety, and just worrying more and more that I was playing with fire.  Would I develop cancer before I could actually do something about it?  It wasn't a way to live.

I felt like a clock was ticking as entered my 30s.  My mother and grandmother were diagnosed by 40.  I was getting closer and closer to that age with each passing year and each passing scan.  From 2010-2014, I lived in the UAE and had no choices for preventive surgery.  But, in 2014, we moved once again, to Singapore.  I found a doctor who referred me to my first MRI and mammogram in Singapore.  Unfortunately, it was my first abnormal scan, they found a cyst.  All that went through my mind was how I waited too long and I shouldn't have done surveillance for so long.  I should have been more proactive.  As I discussed the results of the scan with the doctor, her response was to do a lumpectomy or watch it for six months to see what happens.  WHAT?  I'm BRCA+ and you want to "sit on it"!  I was out of there and began a furious search for an expat doctor.

It was here that I met a phenomenal expat doctor who trained in genetics and oncology at UCLA.  We discussed my recent scan and my history, and he was shocked that I had lasted this long with surveillance.  He was putting wheels in motion after our first meeting.  Luckily, my husband's new insurance covered me in the States, and I could pick the doctor of my dreams and have the surgery I had been waiting for after 10 years.  In 2015, my six month scans were over, and I had my preventive prophylactic mastectomy.

Surveillance isn't for everyone.  As I mentioned earlier, I wished I'd had my surgery right away.  Those 10 years were awful for me.  I hated wondering and not knowing.  I hated taking that risk of waiting.  It's an internal conversation you need to have with yourself, but also with your genetic counselor and doctor.  Do what's right for your situation.  If you have questions and are wondering about how to navigate all this information, please download The Breast Advocate app.

Fat Grafting or No...One of the Most Asked Questions of Me

I had an amazing experience with my surgery, from beginning to end.  I'm one of the ones who truly had a one and done experience.  I chose a phenomenal team at PRMA in San Antonio, using Dr. Chrysopoulo as my surgeon.  Dr. C, as we all affectionately call him, is a microsurgeon and even more importantly, a board certified plastic surgeon skilled in breast reconstruction.  I cannot emphasize enough how important it is to do your research before you settle on a surgeon or surgical team.  You have a choice. You have the right.  You need to choose someone who knows what he/she is doing.  Someone who can connect you to previous patients, someone who can show before and after photos, and most importantly, someone who will listen to YOU.

That being said, I often get asked whether or not I had any fat grafting done after my "one and done" surgery.  The answer is, no.  For me, I feel like my results really couldn't be any better.  Could I be fuller?  Maybe.  Is there animation I wish would be covered?  Slightly.  But is the process worth it?  I don't feel it is, for ME.  Firstly, let me explain what fat grafting is.

File:Breasts.svg - Wikimedia Commons

Fat grafting basically involves taking fat from one part of the body and putting it in another.  In this case, it is most often taken from the stomach or thighs and placed into the breasts via liposuction.  Again, DO YOUR RESEARCH.  You need to make sure the place you're going to does this often, has correct procedures and know how to handle the fat cells properly.  But that's it.  In and out.

So why don't I want to do it?  I don't want to go through any more procedures, I really don't.  But that, on top of the fact that there's no guarantee that the first procedure will stick, added to me thinking it just wasn't worth it.  There's actually a chance that 30-50% of the fat in the first transfer will be reabsorbed by the body.  30-50%!  That's too high for me to think it's worth it.  I'm reading Facebook posts talking about this very thing, weekly.  Women going in for fat grafting, loving the immediate results, but then having reabsorption and having to choose whether to go through another procedure or just leave it alone and be happy with what they have.

So, for those of you who write in and ask if I ever did fat grafting, or why I didn't, there you go.  It was a personal decision and I'm happy with it.  For me, my journey was always about removing my ticking time bombs, not about perfection.  But, I'm pretty damn close, and I'm happy with that.

For answers to questions you might have, check out The Breast Advocate App.