Writing about her decision to undergo a preventative double mastectomy, actress Angelina Jolie stressed, "I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity."
Concerns about body image and the effects on sexual response can naturally arise for women undergoing the invasive procedure, from physiological questions about loss of feeling and pain from scar tissue to psychological apprehension around the consequences for pleasure.
"For most women, it's a very emotional decision," said Kelly Metcalfe, an associate professor at the University of Toronto's Lawrence S. Bloomberg Faculty of Nursing.
Dr. Metcalfe, who researches cancer prevention in high-risk women, said some patients get feeling back and others do not. As for the fraught question of sexual pleasure, "Some women will tell you [breasts] have nothing to do with it. But for some women and their partners, it is a big part."
She acknowledged that while removing a breast "is not going to do anything to the way that you function as a human being, it does have an impact on the way you may perceive yourself as a woman."
When Amy Moore-Benson saw her breasts after reconstruction for the first time, "it was a massive sense of shock," said the Toronto literary agent and mother of three. "It was a very high price to pay. Still worth paying."
Ms. Moore-Benson, 44, underwent a double mastectomy after being diagnosed with aggressive breast cancer in 2008. Although her own appearance initially stunned her, Ms. Moore-Benson insists she did not grow self-conscious about it: She had no issues changing in the yoga studio or walking around nude in front of her husband at the time.
"I did not lose a piece of my sexuality with my breast. I did not ever see it like that, nor do I experience it like that now. ... It's my price that I had to pay to get out of being a cancer patient as quickly and effectively as I possibly could."
For women who decide to proceed with double mastectomies, such questions of body image often dim next to the prospect of a cancer-free life.
"These new breasts will not be the breasts that they've known their entire life. They will feel different, they will probably look different," Dr. Metcalfe said. "But we know that it has very beneficial effects as well. ... Women describe waking up from the surgery thinking, 'I no longer have to worry about breast cancer any more.' "
Aletta Poll, a genetic counsellor at the Women's College Research Institute's familial breast cancer clinic, said that despite generally good aesthetic results with modern mastectomies and reconstructive surgeries (procedures typically done in tandem in Canada), some patients "may not always be absolutely thrilled about the physical outcome." Asymmetry, shifting implants and keloid scarring are all issues, and Ms. Poll said patients do return to their reconstructive breast surgeons for certain fixes.
"This is not cosmetic surgery. This is not like a breast augmentation," Ms. Poll said. "I've had people who've gone back but I've not had them say, 'Man, do I wish I didn't do this.' "
Patients can approach their doctors about short-term psychotherapy and peer support, with some groups for carriers of the BRCA gene mutation even offering "touch and feel" show-and-tell sessions with facilitators who have undergone the procedure, Ms. Poll said.
Ms. Jolie also stressed the support of her partner, actor Brad Pitt. For women whose husbands aren't "that keen," Ms. Poll suggests bringing these spouses along to the doctor so they can hear "what exactly is at stake and get a better perspective."