Breast cancer: Drugs v mastectomy
Women at high genetic risk of breast cancer could soon have a new treatment option other than double mastectomy - preventive drugs.
Draft recommendations from the drugs watchdog in England and Wales, the National Institute for Health and Clinical Excellence, say such women should be given the option of taking tamoxifen or another drug called raloxifene for five years to cut their lifetime risk of the disease.
Until now, women facing a future with a strong likelihood that they would one day develop breast cancer have had only two real options - live in hope that it would never actually happen or have both of their breasts removed.
Three years ago, Emma Parlons, then aged 38 and living in London, discovered she carried a gene called BRCA1, which greatly increased her chances of getting breast cancer.
She says: "Before you are allowed to have your genetic test, they take you through some quite extensive counselling to make sure you understand how you might feel if you were to find out that you were BRCA1.
"I had the blood test and while I was waiting for the results, I decided to have full body screening because I knew it would be really difficult to find out that I had BRCA1 and not know if I had cancer.
"Thankfully I didn't have cancer but going through that screening made me realise that I couldn't live like that.
"It was almost like I prepared myself that I did have cancer to cope with the results."
Emma then discussed her options and decided to have a double mastectomy, with reconstruction, to remove both of her breasts and hopefully any chance that she could develop breast cancer.
"I didn't actually have any doubts at that point. I was ready to go," she says.
Emma had the surgery and a year later decided to have another operation to remove both of her ovaries because, as a BRCA1 gene carrier, she was also at increased risk of ovarian cancer.
Emma says she has no regrets and would do the same again, even knowing that there could be the option of taking preventive drugs instead of having surgery.
"I have not one doubt about my decision. You have to make these big decisions with the information that you have at the time," she says.
"Actually, looking at the odds, the percentages, I would still have my operations today in place of having a drug.
"I think it's really exciting that there could be a drug in the future which would lower my risks as much as the surgery did, and has done, but at this moment in time I would have those operations today.
"It's not as bad as it sounds.
"I felt very empowered because I had saved my life."
About one in every 100 women over the age of 30 falls into the high-risk category for breast cancer that Emma was in. Because of their family and genetic history, another two in every 100 women are at moderate risk and may also benefit from preventive therapy, experts say.
Prof Gareth Evans, an oncologist at Christie Hospital, says for some of those women, taking tamoxifen could be an alternative to having a preventative mastectomy, or breast removal.
"That surgery can reduce the risk by 90-95%, so it doesn't eliminate the risk," he says.
"It's impossible to remove every last breast cell and depending on whether women keep their nipple or not, and that's a big decision for some women, the risk may only be reduced by about 90%.
"We think that in about half of women, tamoxifen actually reduces the risk by 70% - if we can actually identify which women get that extra benefit, that may be enough for those very high-risk women to change their minds and say, 'I'll go for the tamoxifen instead'."
Tamoxifen is not suitable for every woman and can cause side-effects, like hot flushes. Research suggests that up to half of women given tamoxifen to stop a breast cancer returning stop taking the drug prematurely.
Women who want to try for a baby would also need to come off the drug for at least three months before trying to conceive.