HE CONTROVERSY OF DOUBLE MASTECTOMY AS THE

PHROPHYLACTIC MEASURE OF BREAST CANCER

TUTORIAL EVIDENCE BASED LEARNING

by

Group 6B

Airlangga University

Surabaya

November 2016

1
THE CONTROVERSY OF DOUBLE MASTECTOMY AS THE

PHROPHYLACTIC MEASURE OF BREAST CANCER

TUTORIAL EVIDENCE BASED LEARNING

TUTOR

Mohammad Saiful Ardhi, dr., Sp. S

SCENARIO COMPOSER

Fundhy Sinar Ikrar Prihatanto,dr., MMedEd.

Lina Lukitasari, dr., MSi.

Prof. Dr. N. Margarita Rehatta, dr., Sp.An.KIC, KNA

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COMPOSED BY

GROUP 6B

LEADER

Vincent Geraldus Enoch Lusida (011611133146)

SECRETARY

Nurizzah Farahiyah Sofia (011611133148)

MEMBERS

Arinda Putri Auna Vanadia (011611133141)

Nabilah Puspa Utami (011611133142)

Fariz Augusta (011611133143)

Raudatuzzahra Kesuma (011611133144)

Jihan Qonitatillah (011611133145)

Nida’ Fahima Amatullah (011611133147)

Yuthaya (011611133149)

Sekar Afifah (011611133150)

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CONTENTS

Cover ..................................................................................................... 1

Group Member .................................................................................... 3

Contents ................................................................................................ 4

Chapter I : Brain Storming

1.1 Scenario ........................................................................................ 6

1.2 Main Problem ............................................................................... 8

1.3 Keywords ..................................................................................... 8

1.4 First Hypothesis ............................................................................ 8

1.5 First Learning Issues .................................................................... 8

Chapter II : Problem Analysis

2.1 Answers ........................................................................................ 10

2.2 Methods and Steps to Find The Information ................................ 10

2.3 First Analysis ................................................................................ 11

2.4 Second Learning Issues ................................................................ 12

2.5 First Mind Mapping ..................................................................... 18

Chapter III : Tutorial Conclusion

3.1 Answers ........................................................................................ 19

3.2 Second Analysis ........................................................................... 27

3.3 Final Hypothesis ........................................................................... 28

3.4 Group Opinion .............................................................................. 28

3.5 Final Mind Mapping ..................................................................... 29

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3.6 Conclusion .................................................................................... 30

3.7 Obstacles ...................................................................................... 30

Reference .............................................................................................. 31

Journal Appraisal ................................................................................ 34

Critical Appraisal ................................................................................ 37

Acknowledgement...................................................................................41

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 CHAPTER ONE

BRAIN STORMING

1.1 SCENARIO

A female, Jennifer Lopez, did a double mastectomy surgery followed by breast

reconstruction using implants in 2013. This procedure is performed after the

respective detected to have a BRCA1 gene. The controversy arises because of

some differences in viewpoint on this prophylactic surgery.

1.2 MAIN PROBLEM

Jennifer Lopez did double mastectomy surgery followed by breast

reconstruction as prophylactic surgery after detected having BRCA 1 gene.

Controversy arises on this prophylactic surgery

1.3 KEYWORD

BRCA 1, Breast cancer, Double mastectomy, Breast implant, controversy

1.4 FIRST HYPOTHESIS

The patient’s motive to do those procedure are as prevention and aesthetic

purpose

1.5 FIRST LEARNING ISSUES

1.5.1 What is BRCA?

1.5.1.1. How can BRCA be dangerous?

1.5.2 What is breast cancer?

6
 1.5.2.1. What are the risk factors of breast cancer?

1.5.3 What is double mastectomy?

1.5.3.1. How or when does a patient need to have double

mastectomy?

1.5.3.2. What are the effect of double mastectomy?

1.5.4 What is breast implant?

1.5.4.1. What are the impacts of breast implant?

1.5.5 What makes this becomes controversy?

1.5.5.1. From medical point of view, how do we see this case?

1.5.5.2. From social point of view, how do we see this case?

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 CHAPTER TWO

PROBLEM ANALYSIS

2.1 Answer

1.5.1.1 BRCA1 and BRCA2

BRCA1 and BRCA2 is one of the many tumor suppressor genes that works
as; (1) Inhibitor to the replication rate of a cell so it does not overreplicate and (2)
Multifunctional proteins that have a major role in DNA repair (Corwin, 2009).
Classic genetic mapping and cloning studies identified mutations in these genes
that account for the majority of hereditary breast cancer. Genetic deletion of these
genes may cause genomic precariousness and delicacy to transmogrification
(Mendelsohn, 1995).
Most recent clinical findings behest that mutations in BRCA1 and BRCA2
genes are sensitive to blockade of polyADP ribose polymerase (PARP) and the
alternative base-excision DNA repair pathway. Cells with loss of BRCA functions
have no pathway to overcome BER and thus abide cell death (Mendelsohn, 1995).

1.5.1.1. How can BRCA be dangerous?

A recent comprehensive review by the Institute of Medicine reported that

alcohol consumption, postmenopausal weight gain, smoking, lack of exercise, and
hormone restoration therapy are associated to increased risk of breast cancer.
There is also averment for increased risk to divulgence to benzene, 1,3-butadiene,
etylene oxide, chemical pollutants, and gasoline fumes. Mutations in the BRCA
genes are mainly caused by enviromental denunciation, however, age and
hereditary factors should also be included in those category (Mendelsohn, 1995).
Mutations in BRCA often happens in woman before menopausal years and
sometimes in the age of 20s to 30s. Differenct races that may contribute to BRCA
8
mutations can be seen in African-American people and Ashkenazi Jewish people.
Higher prevalence of BRCA genes results in higher tendencies of mutations in
these people.

BRCA mutations may be found in a person having one of these relations;

1. Two first-grade relatives diagnosed with breast cancer or one of them is
diagnosed with it while under 50 years old.
2. Three or more first-grade/second-grade diagnosed with billateral breast
cancer
3. First-grade relatives diagnosed with billateral breast cancer
4. Combination of two or more first-grade/second-grade diagnosed with breast
cancer and ovary with no age restrictions
5. Positive breast cancer diagnosed on a male relative.

1.5.2 What is breast cancer?

Breast cancer is cancer that forms in the cells of the breasts. After skin
cancer, breast cancer is the most common cancer diagnosed in women in the
United States. Breast cancer can occur in both men and women, but it's far more
common in women.
Substantial support for breast cancer awareness and research funding has
helped improve the screening and diagnosis and advances in the treatment of
breast cancer. Breast cancer survival rates have increased, and the number of
deaths steadily has been declining, which is largely due to a number of factors
such as earlier detection, a new personalized approach to treatment and a better
understanding of the disease. (Mayo clinic staff, 2016)

1.5.2.1. What are the risk factors of breast cancer?

There are several risk factors for breast cancer. This risk factor includes
but not limited to;
1. Age

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 The incidence of breast cancer increases with age, doubling about every
decade until the female enters menopause.
2. Age at menarche and menopause
The risk of breast cancer in women who have their first child after the age
of 30 is about twice that of women who have their first child before the
age of 20 (McPherson 2000, p 625)
3. Lifestyle
Lifestyle of someone will heavily affect the outcome of that very person.
Alcohol consumption was positively associated with the risk of invasive
breast cancer (Smith-Walner et al. 1998, p 535). It is also suggested that in
a body of a female with high BMI (Body Mass Index), the fat shall
increase the synthetic of fat. Later on, it may influence proliferation of
breast tissue (Anggrowati, 2013) The commencement of smoking have
demonstrated an acclivity of risk for early initiator. In three studies, the
elevation risk was modest, while in the fourth study, the association
between early smoking and the risk of breast cancer was more pronounced
(Colditz 1995, p 569)

1.5.3 What is double mastectomy?

A mastectomy is surgery to remove a breast or part of a breast. It is

usually done to treat breast cancer. Types of breast surgery include;
 Total (simple) mastectomy: removal of breast tissue and nipple
 Modified radical mastectomy: removal of the breast, most of the
lymph nodes under the arm, and often the lining over the chest muscles
 Lumpectomy - surgery to remove the tumor and a small amount of
normal tissue around it.
1.5.3.1. How or when does a patient need to have
double mastectomy?
The stage of cancer, size of the tumor, size of the breast, and whether if the
lymph nodes are affected will determine which surgery you must take. Females

10
often undertake implants and reconstruction after doing a mastectomy. Sometimes
mastectomy is done to prevent breast cancer. Only high-risk patients have this
type of surgery.
Obese person has higher chances of breast cancer because of insulin
hormones. Obesity may increase insulin and estrogen, which in turn may increase
the risk of breast cancer, especially estrogen. About 5% to 10% of breast cancer
cases are thought to be hereditary, meaning that they are caused by gene defects
(called mutations) passed on from a parent. Excess body weight may affect cancer
risk through a number of mechanisms, some of which might be specific to certain
cancer types. Excess body fat might affect:
• Immune system function and inflammation
• Levels of certain hormones, such as insulin and estrogen
• Factors that regulate cell growth, such as insulin-like growth factor-1 (IGF-1)
• Proteins that influence how the body uses certain hormones, such as sex
hormone-binding globulin
There is evidence that weight loss might reduce the risk of breast cancer
(after menopause). Some bodily changes occur as a result of weight loss suggests
it may, indeed, reduce cancer risk. For example, overweight or obese people who
intentionally lose weight have reduced levels of certain hormones that are related
to cancer risk, such as insulin, estrogens, and androgens. Aside from possibly
reducing cancer risk, losing weight can have many other health benefits, such as
lowering the risk of heart disease and diabetes.

1.5.3.2. What are the effect of double mastectomy?

After having breast cancer surgery, some female have problems with nerve
(neuropathic) pain in the chest wall, armpit, and/or arm that doesn’t go away over
time. This is called post-mastectomy pain syndrome (PMPS) because it was first
described in female who had mastectomies, but it can also happen after breast-
conserving surgery (such as a lumpectomy).
Symptoms of PMPS: The classic symptoms of PMPS are pain and
tingling in the chest wall, armpit, and/or arm. Pain may also be felt in the shoulder
or surgical scar. Other common complaints include: numbness, shooting or
11
pricking pain, or unbearable itching. Most female with PMPS say their symptoms
are not severe.
How common? Studies have shown that between 20% and 30% of female
develop symptoms of PMPS after surgery. PMPS can be treated by some
medicines that work for the pains.

There are several ways to prevent breast cancer. These are 8 ways of many on
how to prevent the breast cancer.
1. Keep weight in check
2. Be physically active
3. Eat fruits & vegetables – Avoid drinking alcohol
4. Don’t smoke
5. Breastfeed, if possible
6. Avoid birth control, especially if you are 35 or smoking
7. Avoid post-menopausal hormones
8. Tamoxifene and raloxifene for female at high risk

1.5.4 What is breast implant?

Breast reconstruction is a type of surgery for female who have had all or
part of a breast removed. The surgery rebuilds the breast mound to match the size
and shape of the other breast. The nipple and the darker area around the nipple
(areola) can also be added. Most female who have had a breast removed
(mastectomy) are able to have breast reconstruction. Female who have had only
the part of the breast around the cancer removed (lumpectomy or breast-
conserving surgery) might not need reconstruction, but sometimes they do.

1.5.4.1. What are the impacts of breast implant?

As other surgeries, breast implant cause some of side effect. Such as

Asymmetry, Breast Pain, Pain in the nipple or breast area, Breast Tissue Atrophy,

12
Thinning and shrinking of the skin, Calcification/Calcium Deposits, Capsular
Contracture, Chest Wall Deformity, etc (FDA, 2013)

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 1.5.5 What makes this becomes controversy?

There are some aspect that make double mastectomy surgery becomes
controversy,there are medical and social aspect

1.5.5.2. From social point of view, how do we see this case?

In the journal written by dr. Arismaswati, dr. Indria Hafizah, and dr.
Syamsul Rizal, SpB, they explained that there four concepts to account for before
taking actions.
The pro for this action is the Autonomy principle (self-determination),
which is the principle which acts to respect the patient’s rights. This case clearly
expresses the will of this 40 year old female to abide the double mastectomy and
implants. This principle will assure that the procedure will be executed promptly,
based on the will of the patient.
The contradiction for this action is the Non-maleficence principle, which is
the principle to not harm patients. If the doctor predestines another course of
action, he may not be upholding the principle. This principle follows the saying
“above all do no harm” which translates to all procedures are not to harm the
patients or anybody else.

1.5.5.1. From medical point of view, how do we see this case?

We already now that double mastectomy bring some of side effects such as
Early complications/7%/: hematoma, skin necrosis, infection. Late complications
/11%/ : relapse of cancer/4%/ and the need for the coverage of the prosthesis/7%/.
Patients evaluated the effect of treatment: 65% – good; 20% – very good; 15% –
bad. (R, Cnarzeki, 2016) but the risk to get breast cancer after double mastectomy
surgery decrease up to 5%

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2.2 Method and Steps to Find The Information

Based on the questions made in the first Learning Issue, we have done our
own researches and compiled together in this Chapter 2. The methods used in
finding the correlating information may include but not limited to;
1. Books
We have used books as our reference and we do not let slip from memory
to write the citations to the books. The books used to construct this report
have been numerous, but most of them come from Molecular Biology,
Pathology, and Pathophysiology.
2. Medical Journal
We have used numerous medical journals, published in websites, taking
the form of PDF files. These are legit medical journals, reviewed by many,
and they are to be trusted by the readers.
3. Internet
The Internet is a vast space, capable of withstanding so much information
that we could not. The sources of our reports came from one of the
websites that lay dormant in the surface web. We strictly forbade any of
our members to find information inside the deep web. However, we only
take materials from website with these suffixes; (1) .edu, (2) .gov, and
(3) .mil, with .edu being the most.

2.3 First Analysis

The patient, Jennifer Lopez, is a 40 year old patient which has been
diagnosed of carrying the BRCA genes in her body. As a result, she desires to
undertake a mastectomy procedure, fearing for her risk of breast cancer. The
patient’s data was not complete, thus rendering some hindrance in our analysis of
why the patient desires this course of action. However, from the scenario, there
could be two possibilities;
1. The patient wishes the procedure to be done under aesthetics motive.
2. The patient wishes the procedure to be done under medical motive.

15
 Either way, if the procedure is done, the patient will lose her breasts.
Considering those two motives, each has their own benefits and handicaps.
If the patient wishes the procedure be done under the aesthetics motive,
there is the Autonomy Principle which dictates that each and every doctor are to
abide and follow what the patient desires for their own body. This is done after
the patient has been informed of the action and all that follow.
If the patient wishes the procedure be done under the medical motive,
there is the Beneficence and Non-maleficence Principle which dictates that each
and every doctor is forbidden to harm the patient or any other person. The chances
of breast cancer does decrease after an auspicious mastectomy procedure, thus,
refusing doctors may be charged with violation of this principle.
Reconstruction may be engaged after the operation; however it has its own
complication. Females often feel neural pain in their chests and sometimes a
complete neuropathy after undergoing these procedures. There are also indications
of skin irritation and inflammation post-surgery.
Whatever motive the patient will be undertaking, the patient should be
well-informed on the procedure; how it is done, the complications, the alternatives,
and many more. If, however, the patient still decides to undergo the operation,
there must be an informed consent to the patient and the surgery must be executed.

16
2.4 Second Learning Issues

From the explanation contained in Chapter 2, we have decided these questions as

the second Learning Issue:
1. What are the controversies caused in this scenario?
2. Are there any alternatives from this procedure?
2.5 First Mind mapping

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 CHAPTER THREE
TUTORIAL CONCLUSION

3.1 ANSWERS
3.1.1 What are the other ways to prevent breast cancer beside do
double mastectomy surgery?

Based on the data that we have collacted it, we found out that there
are some ways to prevent breast cancer. Some of them are habbits that
oftenly ignored but they can significantly prevent us from suffering breast
cancer. Such as Avoid exposure to light at night. Exposure to light at night
may increase the risk of breast cancer by suppressing the normal nocturnal
production of melatonin by the pineal gland, which, in turn, could increase
the release of estrogen by the ovaries. The other way is to avoid working
overnight since its also has to do with exposure from light. Also, reduce the
consumption of alcohol. Alcohol can increase levels of estrogen and other
hormones associated with hormone-receptor-positive breast cancer.
Alcohol also may increase breast cancer risk by damaging DNA in cells
The other way to prevent breast cancer is mammography.
Mammography is an x-ray imaging method used to examine the breast for
the early detection of cancer and other breast diseases. It is used as both a
diagnostic and screening tool. During a mammogram, a patient’s breast is
placed on a support plate and compressed with a parallel plate called a
paddle. An x-ray machine produces a small burst of x-rays that pass
through the breast to a detector located on the opposite side. The detector
can be either a photographic lm plate, which captures the x-ray image on
lm, or a solid-state detector, which transmits electronic signals to a
computer to form a digital image.
A radiologist will carefully examine a mammogram to search for
areas or types of tissue that look different from normal tissue. These areas
could represent many different types of abnormalities, including cancerous
tumors, non-cancerous masses called benign tumors, broadenomas, or
complex cysts. Radiologists look at the size, shape, and contrast of a mass,
as well as the edges or margins, which can indicate the possibility of
malignancy (i.e. cancer). They also look for tiny bits of calcium, called
microcalcications, which show up as very bright specks on a mammogram.
For many difficult cases, x-ray mammography alone may not be
sufficiently sensitive or accurate in detecting cancer, so additional imaging
technologies, such as ultrasound or magnetic resonance imaging (MRI)
may also be used to increase the sensitivity of the exam. Finally, although
18
 the majority of abnormal mammograms are false-positives, when cancer is
present, early detection can save lives.

Because mammography uses x-rays to produce images of the breast,

patients are exposed to a small amount of ionizing radiation. However, the
benefits of using mammography to detect breast cancer under age 40 may
outweigh the risks of radiation exposure. If a tumor is malignant and is
caught early by mammogram, a surgeon may be able to remove it before it
spreads and requires more aggressive treatment such as chemotherapy.
(Anonym, 2013)

3.1.2 What are there the controversies on doing mastectomy surgery

and breast implant?

There are much controversies in term of medical ethics, medical

law, religion, social, health, and psychological.

3.1.2.1 Controversy in medical ethics aspect

Based on Journal written by dr. Arimaswati, dr. Idriya Hafizah, dr.

Syamsul Rizal, Sp.B, explained that there are four rights that needs to be noted on
deciding any action.
On the pro side, autonomy principal (self-determination), which is principe
of respecting patient rights, in this case, is fully objected that the desire of this
40th years old woman to perform double mastectomy surgery followed by breast
implant is very strong. In this case, whether they accept the treatment or not is all
their right.
On the cons side is non-maleficent principle. If the doctor decided not to
perfom those action, it means that the doctor have applied the principal mentioned
above. This principe fulfilling “above all do no harm” standard means any action
wont hurt or harm the patient.

3.1.2.2 Controversy in medical law aspect

Based on Indonesia’s Penal Code:

LAW OF THE REPUBLIC OF INDONESIA NUMBER 29 YEAR 2004
REGARDING THE MEDICAL PRACTICE
CHAPTER VII
THE PROCEDURES OF MEDICAL PRACTICE

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 PART THREE
THE PROCEDURE IN GIVING THE MEDICAL SERVICE
Paragraph Five
The Control for Quality and Budget
ARTICLE 49
1. Every doctor/dentist who conducts medical practice must consider the
control for quality and budget.
Article 49
Clause (1)
The quality control is a system of efficient, effective, and qualified medical
service given to the patient in order to fulfill the needs of patient. The budget
control is the medical service financing which is suitable with the medical
treatment that the patient needs. The fee has been regulated in the regulation
In our opinion, we think that the practice of mastectomy in this scenario
violates this law. In the scenario, the patient don’t have to go through the double
mastectomy operation, because there is another option to overcome the problem
such as mammography inspection. By using mammography, not only does the
patient don’t have to go through an operation, it is also more economical for the
patient. As a doctor, we have to recommend the most efficient way while giving
the effect with qualified medical service.

3.1.2.3 Controversy in religion aspect

There are 72,65% of indonesian people, means 1.235.556 choose islam to
serve as a guide in life. People consider that double mastectomy operation or
breast implant is allowed in islam . The guide in islam called Al-quran dan Hadist.
There are some paragraph in Alquran dan Hadiths about prohibition to change
Allah's creation.

ِ َ‫يَا أَيُّ َها الَّذِينَ آ َمنُوا ََل ت َأ ْ ُكلُوا أ َ ْم َوالَ ُك ْم بَ ْينَ ُك ْم بِ ْالب‬
َ ‫اط ِل إِ ََّل أ َ ْن ت َ ُكونَ تِ َج‬
‫ارة ً َع ْن ت ََراض‬
29:‫َّللاَ َكانَ بِ ُك ْم َر ِحي ًما)النساء‬ َّ ‫س ُك ْم إِ َّن‬ َ ُ‫) ِم ْن ُك ْم َو ََل ت َ ْقتُلُوا أ َ ْنف‬
"Oh believers! Do not consume one another's wealth through
unlawful means; instead, do business with mutual consent; do not
kill yourselves by adopting unlawful means. Indeed Allah is
Merciful to you."

Every operation has purpose, if it's for treatment and if they do not the
operation, they will die or suffered throughout their life.
Syeikh Dr Yusuf Al-Qaradawi said " if they disability maybe people disguist to
20
see them, moroever the patient feels stress, no mistake from them while they
purpose surgery to dismiss the pain. Because Allah didn't make this religion to
lurch"
We know from paragraph above that we can do operation for treatment in right
purpose. Not for beauty and aesthetics.

‫ضلَّنَّ ُه ْم َو ََل ُ َم ِِّن َي َّن ُه ْم‬

ِ ُ ‫) َو ََل‬118( ‫َصيبًا َم ْف ُروضًا‬ ِ ‫َّللاُ َوقَا َل ََلَت َّ ِخذَ َّن ِم ْن ِع َبادِكَ ن‬ َّ ُ‫لَ َعنَه‬
ِ ‫طانَ َو ِليًّا ِم ْن د‬
‫ُون‬ َ ‫ش ْي‬ َّ َ‫َو ََل ُم َر َّن ُه ْم فَلَيُ َب ِتِّ ُك َّن آذَانَ ْاَل َ ْن َع ِام َو ََل ُم َرنَّ ُه ْم فَلَيُ َغ ِي ُِّر َّن خ َْلق‬
َّ ‫َّللاِ َو َم ْن َيت َّ ِخ ِذ ال‬
118-119:‫َّللاِ فَقَدْ َخس َِر ُخس َْرانًا ُم ِبينًا )النساء‬ َّ )
"Whom Allah has cursed. For he had said, "I will surely take from
among Your servants a specific portion. And I will mislead them,
and I will arouse in them [sinful] desires, and I will command them
so they will slit the ears of cattle, and I will command them so they
will change the creation of Allah ." And whoever takes Satan as an
ally instead of Allah has certainly sustained a clear loss."

This paragraph explain us about forbidden to change His creation,

excoriation, and some punishment who change a part of body without the right
reason.

3.1.2.3 Controversy in social aspect

There are several factor that can relate to a female life after undertaking
breast surgery or mastectomy, this factors may include but not limited to; (1) age,
(2) occupation, and (3)marital status. According to research woman under the age
of 50 were better after mastectomy than after BCS (Breast conservative surgery)
ina physical (p=0,001) and functional well-being (p=0,059). Better physical and
functional well-being are also observed in employed woman that undertook
mastectomy. However, there are no statistically reliable difference in the quality
of life among married woman. This differs in the group of unmarried woman,
physical well-being was better after mastectomy than after BCS (p=0,045).

3.1.2.4 Controversy in health aspect

There is no indication that leads Jennifer Lopez tpo suffer from breast
cancer. BRCA1 also means that she is potentially suffering from tuba fallopii and
ovary cancer. On pro side, double mastectomy surgery can prevent from breast
cancer effectively.
However, the controversial side of this procedure may include neuronal
units detrimentation, causing severe neuropathy, inflammation, hematoma, and
sometimes irritation to the skin.

21
Complications of mastectomy
Seroma formations (25–
60%)
Wound infections (2.8–15%)
Skin flap necrosis (1–22%)
Hematoma (2%)

Complications of implants
Prosthesis infection (0.5–2%)
Capsular contraction (3–5% up to 30% depending on type of implants)
Device failure and rupture (10%)

Complications of autologous tissue

reconstruction
Flap necrosis (1–3%)
Wound infection (4–8%)
Functional impairment (variable)
Abdominal hernias (20%)

Besides, the main purpose of risk reducing mastectomy is to prevent the

occurrence CBC and in the end to increase life expectancy. This risk is increased
in BRCA1-2 carriers who have been showed to have a risk of breast recurrence
from 25% to 86% according to the different studies. On the other hand, the
potential benefit in patients with sporadic breast cancer is less clear.
A paradox now exists in which the conservative management of breast
cancer has achieved outstanding outcome and the majority of women are suitable
for limited excision, while amputation of the breast is used for breast cancer
prevention. The increasing use of CRRM in patients with sporadic breast cancer is
almost certainly unjustified in terms of oncologic outcome improvement. Patients
with sporadic breast cancer should be made aware that the lifetime risk of CBC is
very limited and that effective methods are available to make an early diagnosis in
the unlikely event of a second tumor in the contralateral breast. For these reasons
according to the results of a recent meta-analysis, it appears extremely unlikely
that CRRM can translate in improved survival in women without increased
genetic risk. Psychological support should be highly encouraged to cope fears and
uncertainties but treating physicians should provide patients with clear
information to take the best decision for the single person. Surgeons should also
be very clear and honest in explaining the possible complications patients might
encounter when undergoing a procedure aimed at reducing a limited risk and not
22
at curing the disease. Finally, patients should be made aware that CRRM is highly
reducing the risk but is not going to 100% eliminate the risk of developing breast
cancer of the contralateral breast in the future. Reconstruction, especially with
autologous tissue or with improved techniques and materials, might mitigate some
of the psychological effects at the cost of more extensive surgery, but can never
restore a completely natural breast and is associated with a substantial increase in
financial cost and patient morbidity.

3.1.2.6 Controversy in psychological aspect

Based on the research that has been done by Bresser, after the surgeries,
almost all women (97%) feel altered by the procedures. Fifty-eight (51%)
women rated their breast are not feeling ‘like their own’, 32 women reported
altered feelings of feminity after the procedure while only 8 women (8%) thought
their partners found them less feminine. On the other side, ten women (13%)
experienced positive changes in their sexual course after the procedure. Forty
women (44%) reported an adversed change in term of sexual relationship. Finally,
10 of the partners (13%) were thought to have experienced a positive change in
their sexual relationship, whereas 27 partners (35%) were thought to have

experienced an adverse change in their sexual activities.

The result of research shown as the table below.(Bresser, 2009)

23
(http://repub.eur.nl/pub/16411/090513_Bresser,%20Paula%20Johanna%Cathari
na%20.pdf)

3.2 SECOND ANALYSIS

Jennifer Lopez came to the hospital to do complete check up on her health.
After it turns out that she has BRCA1 gene, she asked for perfoming double
mastectomy because of her anxiety. But there is no evidence indicating that the
BRCA1 genes in Jennifer Lopez ‘s body has mutated and will do harm on her. It
means the double mastectomy surgery followed by breast implant are not
necessarily needed. Because there are many side effect from performing these
surgeries. Even if these surgeries are fullfilling autonomy of the patient, the doctor
better gave her advices and explained both of the surgeries and the side effects of
both surgeries. So that Jennifer Lopez can rethink on deciding the procedure she
will follow.

Moreover, the mutation of BRCA1 gene not only indicating the possibility
of breast cancer, but also other kind of cancer such as tuba fallopi cancer and
ovary cancer. Not only potentially suffering any side effect but also loss in term of
financial.

The best way to deciding the next procedures is to check whether she
really suffer from the disease or not, and we can also do regular check up to
prevent the breast cancer to occur. But the doctor still has right to perform the
surgeries for the sake of fullfilling the autonomy right of the patient

3.3 FINAL HYPOTHESIS

Jennifer did the performance for aesthetical reason.

3.4 GROUP OPINION

The main reason on why Jennifer Lopez decided to perform double
mastectomy followed by breast implant is to gain her confidence with beautify
herself. There is no evidence that indicate the mutation of BRCA1.

24
3.5 FINAL MIND MAPPING

3.6 CONCLUSION

According to the data that we have collacted, we know that Jennifer Lopez
did not definitely suffer from breast cancer. The detected BRCA1 genes in her
body don’t indicate that she has breast cancer caused by mutated BRCA1 genes.
Moreover, mutated BRCA1 not always indicate that the patient suffer from breast
cancer, but also the other disease, which not suppose the patient to perform double
mastectomy surgery and breast implant. Although the patient fulfilled the
satisfaction, on the other side Ms. Jennifer will get some side effects which is
even hurt herself.
Based on the data that we have, we can conclude that Ms. Jennifer Lopez d
id the performance for aesthetical reason.

3.7 OBSTACLE
25
1. In terms of looking for the materials for the development of this report,
actually we found a very abundant amount of information. But it
become difficult when we have to consider which article or news or
books or journals is relevant to the case
2. There are some difficulties to determind the validity of the journal
3. When cross refferencing some information that we have, sometimes the
information simply contradict each other wher a deeper and longer
learning are necessary to find which information is more valid.

26
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29
 LEMBAR SCIENTIFIC PAPER APPRAISAL
(TELAAH KRITIS TULISAN ILMIAH)

Nama / kelompok / NIM : Kelompok 6B

Arinda Putri Auna Vanadia 011611133141
Nabilah Puspa Utami 011611133142
Fariz Augusta 011611133143
Raudhatuzzahra Kesuma 011611133144
Jihan Qonitatillah 011611133145
Vincent Geraldus Enoch L. 011611133146
Nida’ Fahima Amatullah 011611133147
Nurizzah Farahiyah Sofia 011611133148

Item Presentness

 Judul (Title) Present, 23

 Abstrak dan/atau Ringkasan (Abstract and or Summary) Present , 23

 Pendahuluan (Introduction, background) Present 24

 Bahan dan Cara (Method) Present , 24 – 25

 Hasil (Result) Present , 25 – 29

 Diskusi (Discussion) Present , 29 – 31

 Ucapan terima kasih/ penghargaan (acknowledgement) Present , 31

30
 Daftar Pustaka (Reference) Present , 31 – 32
 Yuthaya 011611133149
Sekar Afifah Priandhini 011611133150
Judul paper : Satisfaction with Prophylactic Mastectomy and
Breast Reconstruction in Genetically Predisposed Women
1. PAPER COMPREHENSIVENESS
Kesimpulan : format lengkap

2.TELAAH VALIDITAS PENELITIAN

Tujuan penelitian : Assessed satisfaction with breast reconstruction after

prophylactic mastectomy in the longer term in a group of
women at increased risk of (contralateral) breast cancer due to
a BRCA1/2 mutation or a supposed genetic predisposition.

Metode penelitian
Item telaah Temuan (sebutkan berikut halamannya)
Disain/rancangan They developed a brief self-report questionnaire based on
(design) clinical experience with high-risk women and on
questionnaires that are currently used in follow-up studies,
in order to measure the satisfaction of women with the
outcome of PM and BR. The questionnaire was mailed to
all patients who met the inclusion criteria.
* Tingkatan A Retrospective Cohort Study.
dalam hierarchy
of evidence
Sampel (sample) All women (n=136) with genetically predisposed and
high-risked for breast/ovarian cancer who underwent
bilateral or contralateral PM/BR at the Family Cancer
Clinic of the Erasmus MC-Daniel den Hoed Cancer Centre
in Rotterdam between 1994 and 2002.
Ukuran sampel Of 136 women who received the questionnaire, 114
(sample size) participated in this study (84%). Two-third of these
women (n=77) were unaffected BRCA1/2 mutation-
carriers (n=63) or 50% risk carriers (n=14); 22 women had
previously been treated for breast cancer by either breast
conserving therapy (n=13) or unilateral mastectomy (n=9).
Fifteen women decided for bilateral mastectomy with
31
 reconstruction when breast cancer was diagnosed. None of
these women experienced a recurrence of breast cancer in
the years after surgery until time of assessment. Thirteen
out of 37 women with a history of breast cancer were
proven BRCA1/2 mutation-carriers.
Kriteria inklusi All women who underwent bilateral or contralateral
(eligibility PM/BR at the Family Cancer Clinic of the Erasmus MC-
criteria) Daniel den Hoed Cancer Centre in Rotterdam between
1994 and 2002. PM/BR was performed because of an
increased risk of (a new) breast cancer due to either a
BRCA1 or BRCA2 mutation, or a 50% risk carrier status
in women from hereditary breast/ovarian cancer families.
All women were from families with cancer following an
autosomal dominant pattern of inheritance. Some of these
women remain at increased risk of breast and/or ovarian
cancer without the possibility that this risk can be
specified further. Reconstruction was done by means of
subpectorally implanted silicone prostheses. A history of
breast cancer was not an exclusion criterion.
Metode By doing a follow-up on all women with genetically
penentuan predisposed and high-risked for breast/ovarian cancer who
sampel underwent bilateral or contralateral PM/BR at the Family
(sampling frame) Cancer Clinic of the Erasmus MC-Daniel den Hoed
Cancer Centre in Rotterdam between 1994 and 2002. The
institutional review board approved the study. Written
informed consent from participants was obtained.
Metode Sending a brief self-report questionnaire based on clinical
pengumpulan experience with high-risk women and on questionnaires
data that are currently used in follow-up studies to all patients
who met the inclusion criteria. The patients completed and
returned the questionnaire by mail.
Cara pengukuran They made some tables consisting statistics from the
(measurement questionnaire that has been done previously. These tables
and or shown a series of numbers of the patients who answered
assessment) the sixteen questions that covered four domains: 1) general
and PM/BR-specific satisfaction (three questions); 2)
feeling informed about the procedure and its possible
consequences (two questions); 3) peri- and postoperative
complications, physical complaints and limitations
because of PM/BR (three questions); and 4) effects on
body image and sexuality (eight questions) with a five-
point scale ranging from ‘Yes!’, ‘Yes’, ‘?’ (neutral), ‘No’,
32
 to ‘No!’. Furthermore, they dichotomized the original 5-
point scale by combining the 'Yes!' and 'Yes' answers on
the one hand and the '?', 'No' and 'No!' answers on the
other hand for the outcome variables alone.
Instrumen yang A brief self-report questionnaire based on clinical
dipergunakan experience with high-risk women and on questionnaires
(instrument) that are currently used in follow-up studies, in order to
measure the satisfaction of women with the outcome of
PM and BR. Sixteen questions covered four domains: 1)
general and PM/BR-specific satisfaction (three questions);
2) feeling informed about the procedure and its possible
consequences (two questions); 3) peri- and postoperative
complications, physical complaints and limitations
because of PM/BR (three questions); and 4) effects on
body image and sexuality (eight questions). All questions
addressed BR specifically. Three questions concerning
body image and sexuality addressed the perception of the
women about their partners’ satisfaction. Answers were
rated on a five-point scale ranging from ‘Yes!’, ‘Yes’, ‘?’
(neutral), ‘No’, to ‘No!’. Questions that implicated the
presence of a partner could also be scored as 'not
applicable'.
Metode From the database of a follow-up study on the medical
randomisasi effects of PM in genetically predisposed and high-risk
(randomization) women, they approached all women who underwent
bilateral or contralateral PM/BR at our institution between
1994 and 2002.
Intervensi -
(intervention)
Metode analisis / They try to relate the obtained data with patients’
pengolahan data satisfaction and the impact of PM/BR on perception of
(analysis sexual relationship by making the statistics of the satisfied
method) and non-satisfied patients by listing the numbers of them
with these questions; (1) Feeling insufficiently informed,
(2) Surgery did not meet expectations, (3) Complications,
(4) Complaints, (5) Limitation in daily life, (6) Change in
feeling of the breasts, (7) Change in feelings of femininity,
(8) Positive effects sexual relationship, (9) Adverse effects
sexual relationship, (10) Would not opt for PM again, (11)
Would not opt for BR again, (12) Partner’s perception
Decrease wife’s femininity, (13) Positive effect on sexual
relationship, and (14) Adverse effect on sexual
33
 relationship. And also the statistics of patients with no
effect and adverse effect on sexual relationship with these
questions: (1) Does not feel sufficiently informed, (2)
Surgery did not meet expectations, (3) Complications, (4)
Complaints, (5) Limitations in daily life, (6) Non-satisfied
result reconstruction, (7) Changed feeling in one or both
breasts, (8) Breasts do not feel 'like your own', (9) Change
in feelings of femininity, (10) Would not opt for PM
again, (11) Would not opt for BR again, (12) Partner’s
perceptions Decrease in his wife’s femininity, and (13)
Adverse effect on sexual relationship.

Kesesuaian antara disain dan tujuan penelitian : sesuai

Kesesuaian cara pengukuran dan instrument yang dipergunakan : sesuai
Kesimpulan : valid

3. TELAAH IMPORTANCE PENELITIAN

Although other studies have shown that PM/BR obviously serves to
decrease cancer-related anxiety in the short term, the long-term impact on
quality of life and especially on the quality of the sexual relationship should
not be underestimated.
In doing this research, researchers have done the right path in order to
build a cohort study. It can be proven by the way they followed only one
population through a particular span of time with no intervention.

34
 ACKNOWLEDGEMENTS

Special thanks to :

1. Almighty God

2. Our tutor, Mohammad Saiful Ardhi, dr., Sp. S

3. PBL academics

4. Our families

5. Our friends and seniors

6. Everyone who supports us

35