Conversation with Dr Jane O'Brien, Specialist Breast Surgeon

29 Sep 2021

Introducing Dr Jane O'Brien

My name is Jane O’Brien and I am a Specialist Breast Surgeon in private practice in the inner city Melbourne suburb of East Melbourne. My surgical practice is almost exclusively devoted to surgery for breast cancer and risk-reducing surgery for women at high risk of developing breast cancer, often because of the presence of an abnormal gene mutation such as the BRCA1 or 2 gene.

What is the role of a breast surgeon and when would a woman have an appointment with you?

The breast surgeon is almost always the first specialist to whom a patient with a highly suspected or proven breast cancer diagnosis is referred, and as such, in effect acts as the gatekeeper to the entire multidisciplinary treatment team. Choosing your breast surgeon is therefore an important decision. Your decision may be guided by a number of influences, including your general practitioner and word of mouth. Ask family friends and ideally, aim to find someone whom has been through the experience.

Some breast cancers are diagnosed through BreastScreen, the government mammographic screening service, and others are diagnosed by general practitioners after a patient presents to their gp with a breast symptom such as a breast lump. Often the gp will arrange breast imaging, such as mammography and ultrasound, and if that raises suspicion, a referral may at that stage be initiated to a breast surgeon, who may see the patient, take a history, perform a breast examination and arrange a needle biopsy of the lump to establish a diagnosis or, in some cases, may first arrange for a needle biopsy to be undertaken prior to the clinical consultation, in order to streamline the process and to expedite a diagnosis.

If the needle biopsy confirms the presence of a breast cancer, the breast surgeon and the breast care nurse may then arrange further tests, such as breast MRI scan. The case will then be discussed in a multidisciplinary meeting attended by multiple cancer specialists in order to ascertain the most appropriate treatment plan, and genetic testing may be discussed. 

What should a woman consider in planning for a preventative mastectomy /reconstruction?

In order to make informed decisions about risk management, women must undergo an accurate risk assessment, which takes into account age-related breast cancer risk according to their particular gene mutation and also their family history. For example, in a young woman with a BRCA1 mutation and multiple close relatives with very young onset breast cancer, one is going to be more worried about early onset breast cancer than in a BRCA2 mutation carrier with a family history of ovarian cancer only. The timing of risk-reducing surgery may be influenced not only by cancer risk-reduction but also by social factors, such as childbearing, breastfeeding, family responsibilities, career and lifestyle.

Consultation with a clinical psychologist, who is knowledgeable and familiar with the impact of risk-reducing surgery, is often useful. The decision to undergo risk-reducing surgery can be a complex one and even after a decision has been made, the process including surgery and beyond can be physically and emotionally challenging. In my own experience, which is supported by the literature, the strongest predictor of a gene carrier electing to undergo risk-reducing mastectomy, is the experience of breast cancer in a close family member, especially her mother.

In risk-reducing surgery, whilst cosmesis is very important, the main motivation for the patient needs to be risk-reduction. I always advise my patients to get as healthy as possible before surgery; to achieve an ideal weight if possible, obviously do not smoke and preferably increase their core strength. 

What are they key questions she should be asking her surgeon?

  • Is there a rush for me to come to a decision about my breast cancer surgery?
  • Do you specialize in the treatment of breast disease only?
  • Do you have special training and experience in advanced breast surgical techniques?
  • How many new breast cancers do you treat per year?
  • How may risk-reducing mastectomies have you undertaken?
  • Do you work as part of a multidisciplinary team?
  • Will my case be discussed in a multidisciplinary team meeting?
  • Do you have a breast care nurse as part of your team?

Are there different options available for women in relation to breast surgery?

In relation to risk-reducing surgery:

  • Is the breast surgeon happy for the nipples to be spared?
  • What types of reconstruction are offered by the team?
  • Do they offer the full range of implant and tissue flap options?
  • Is the surgeon and their team up to date with new and innovative techniques?
  • Can I go direct-to-implant (DTI)?
  • Can I have the implant in front of the muscle (pre-pectoral)?

In relation to breast cancer surgery:

  • Does the breast surgeon offer oncoplastic options?
  • What if I would like a breast reduction at the time of my breast cancer surgery?
  • Is immediate reconstruction at the time of mastectomy routinely offered?

What’s the difference between breast conservation surgery and mastectomy?

Mastectomy is removal of all or almost all of the breast tissue. Breast conservation is, as the name suggests, when the breast is conserved and is also often known as “wide local excision” or referred to as “lumpectomy”.