General Anesthesia

[Natasha]

Hello, I have one copy of APOE4 and I will be getting a prophylactic mastectomy and reconstruction early next year due to having LCIS. I will be getting a flap procedure and without explaining what that is I will just say that I will be under general anesthesia for 10 hours. The surgeon is one of the best in the world so I'm not concerned about the surgery, however, I am quite concerned about the general anesthesia as I have read that it can have an adverse effect on long term cognition in some people and I suspect (though it hasn't been studied) that this effect is greater in those who are APOE4 positive.

This is very difficult for me as I feel like I have to choose between breast cancer and Alzheimer's. As it stands right now, I also have chronic Lyme and have been "slow" as a result for quite a while now.

Any thoughts?

[karelena]

Hi, there's a long discussion about anesthesia under the topic "General Anesthesia and APOE4." If you enter that topic in the search field it will link to the discussion. No, you should not have to choose between breast cancer and AD. One thought I have is asking about a thoracic epidural to decrease the amount of general anesthesia that is needed, but you should read the whole discussion.

[NF52]

Hello, I have one copy of APOE4 and I will be getting a prophylactic mastectomy and reconstruction early next year due to having LCIS...I will be under general anesthesia for 10 hours. ... I am quite concerned about the general anesthesia as I have read that it can have an adverse effect on long term cognition in some people and I suspect (though it hasn't been studied) that this effect is greater in those who are APOE4 positive.

This is very difficult for me as I feel like I have to choose between breast cancer and Alzheimer's. As it stands right now, I also have chronic Lyme and have been "slow" as a result for quite a while now.

Any thoughts?

Hi again, Natasha!
You raise an important question, and you may want to talk to your surgeon about your specific concerns and about his reasons for wanting to do both procedures at once, versus waiting a period of time between them.

As for your ApoE 3/4 affecting your brain health, here is some research from 2010 that may relieve your worry a bit. In 2010, a study compared 270 people over the age of 65 who had surgery with people the same age without surgery. They all completed cognitive testing before surgery (or at a baseline visit without surgery) and then again 8 days, 4 and 13 months later.

This is what they found: a brief downward turn right after surgery, then

with regard to long-term changes we observed improvement compared to controls in most verbal tasks (probably due to learning effects). On the other hand, a clear dissociation effect was observed for several areas of visuospatial functioning which persisted up to the 13-month follow-up. This specific pattern of visuospatial deficit was found to be independent of apolipoprotein E genotype and closely resembles what has recently been termed vascular mild cognitive impairment...The observation of only minor differences between persons operated by general and regional anesthesia makes it difficult to attribute these changes directly to the anesthetic agents themselves, suggesting that cognitive dysfunction may be attributable at least in part to peri-operative conditions, notably stress and glucocorticoid exposure.

Long-Term Post-Operative Cognitive Decline in the Elderly: The Effects of Anesthesia Type, Apolipoprotein E Genotype, and Clinical Antecedents

"independent of apolipoprotein E genotype" means the people with ApoE 4 had NO HIGHER RISK than those without. The effects occurred on some people who had general or regional anesthesia, which suggested it was more likely to occur because of underlying vascular disease in these seniors.

Even some research that reports ApoE4 effects from anesthesia leaves out important information. A small report from 2016 stated that 312 people with ApoE 4 who had surgery between their first and second cognitive testing visits as part of the Wisconsin Registry for Alzheimer's Prevention (WRAP) showed some decreases on testing, https://aanddjournal.net/article/S1552- ... 8/abstract

It didn't mention that:

* the current average of their participants is 67
* 41% have one or two copies of ApoE 4
* 73% have a family history of AD
* 40% are obese
* 40% have high blood pressure
* 10% are diabetic
* 50% have high cholesterol
http://www.wai.wisc.edu/research/whatiswrap.html

They also didn't analyze the types of surgery, to rule out serious underlying health conditions that might have contributed to lower scores on the second visit. A biostatistician (someone who specializes in figuring out how to do a valid statistical analysis on a group of variables) probably would say that unless they controlled for the effects of diabetes, high blood pressure, obesity and other health conditions on the results, it is impossible to conclude that ApoE4 is the cause of changes seen.

So unless you suddenly became an obese, diabetic 67 year old with a family history of Alzheimer's and high blood pressure, I don't think there is sufficient evidence to say you have to choose EITHER breast cancer or Alzheimer's. Your risk of late-onset AD after 65 is no more than 20-25% if you're 60 and older with ApoE 3/4; this surgery will not catapult you into dementia. Do what feels right for you, and know that you have decades of healthy living to enjoy!

[Natasha]

A very belated thank you to you, NF52. Your responses are always so thoughtful and comforting and very much appreciated. Long story but I did decided at the last minute to not go through with the surgery and right now I'm focusing on learning everything I can about APOE4 and making positive lifestyle changes.

[Natasha]

Thanks to you as well, Karelena.

[NF52]

A very belated thank you to you, NF52. Your responses are always so thoughtful and comforting and very much appreciated. Long story but I did decided at the last minute to not go through with the surgery and right now I'm focusing on learning everything I can about APOE4 and making positive lifestyle changes.

Welcome back!!
I’m glad my response was helpful, and even more glad that you’re turning this into a chance to set your own course! We are each way more than a statistic and we can use what we know to find a way forward. Happy 2021!

[Natasha]

Thank you NF52 : ) and Happy New Year to you as well!