Breast reconstruction: It's a personal decision
St. Louis Post-Dispatch (MO)
June 27--When I received my second diagnosis of breast cancer in November, it came with good and bad news.
The good was that, unlike the first, Stage 3 cancer, this one was in the early stages. No chemotherapy or radiation would be required. The bad was that the treatment was surgery: a mastectomy, removing the entire breast.
The first time, I had no decisions to make; I did what I was told to save my life. The second time, I had a big one: Whether or not to undergo reconstructive surgery. It's an intensely personal decision, and it involves more than body image. A little research at the beginning can help to ease possible regrets later on.
Actress Angelina Jolie recently put the subject in the foreground when she went public with her own situation: With a genetic disposition to breast cancer, she had pre-emptive mastectomies and reconstruction. Most women have to make their decisions quickly, in the emotionally charged wake of a fresh cancer diagnosis.
Almost 300,000 women receive new breast cancer diagnoses each year. That's a lot of decisions, and oncologists and surgeons come at them from different perspectives.
Dr. Matthew Ellis is chief of the breast oncology section at the Siteman Cancer Center, and an internationally noted researcher into the causes and cures of breast cancer. He's opposed to leaping into anything without consulting a full team of physicians.
"My personal, deeply felt belief is that (patients) are best served if they can have a decision made in collaboration with a medical oncologist, a surgeon and a radiation oncologist, so that a balance can be set," he said.
Mastectomy and reconstruction offer "an incredibly complex set of issues," he added. The option to have reconstruction "is always there, but often inappropriate. Patients need to be carefully counseled as to the real risks and benefits of going through reconstructive surgery."
Jolie's situation is rare. When breast cancer is present, reconstructive surgery must be carefully timed with chemotherapy and radiation, Ellis said. "People who've been through chemotherapy are at high risk" of complications.
For decades, breast cancer has been treated with "cut, burn and poison" -- surgery, radiation, chemo. In recent years, the order has changed, with chemo coming first and often shrinking the tumor to the point where it's possible to have a lumpectomy instead of a mastectomy.
Increasingly, said Ellis, "we're trying to get the systemic therapy, the chemotherapy, out of the way first. Only when that's all complete, when the patient is healed (from chemo), do we proceed with mastectomy and reconstruction. The cure for breast cancer is the priority."
Radiation adds "a real wild card" to the equation, he said. If breast implants are already in place, it can damage them, as well as the overall appearance of the breast. It also can damage the chest wall, making reconstruction more difficult, and can result in complications.
Dr. Julie A. Margenthaler, a surgeon at Siteman, focuses her practice on breast cancer. "Reconstruction is a part of every single discussion I have" with new patients, she said. "There are very few contraindications (for it). I would say that the surgical decisions are more focused on the breast surgeon and the plastic surgeon."
Margenthaler said she usually offers immediate reconstruction, done at the same time as the mastectomy. Federal law mandates that insurance cover it. "I help (the patient) understand how she would look with and without reconstruction, and what it would feel like."
Margenthaler agrees that chemo and radiation are considerations, and that killing cancer cells comes first, but noted that there are ways to preserve appearance that don't get in the way of treatment. "There are some data out there to suggest that there are psychological and emotional benefits to reconstruction, with self-image and issues of sexuality."
Reconstruction at the time of the mastectomy means better-looking results; skin and sometimes nipples can be preserved. It does come at a cost. Reconstruction adds to recovery time and the number of procedures, it adds pain, and there can be complications, some of them serious. The reconstructed breast "is all look, no feel," said Margenthaler. "There's no sensation."
When implants are used, spacers are put under the muscles of the chest wall. Over a period of months, they're injected with saline solution until they reach the desired size; then permanent implants are put in place. When the patient's own tissues are used (the technical term is "autologous"), a muscle flap is cut from the back or abdomen and secured in place. The recovery time is longer, and there can be permanent loss of muscle strength.
Dr. Marissa Tenenbaum is a plastic surgeon with a focus on breast issues. She said that she consults with oncologists -- "cancer treatments come first" -- but she believes "the vast majority" of women are candidates for immediate reconstruction.
Nationally, half of all mastectomy patients have reconstruction. "In St. Louis," Tenenbaum said, "especially at Siteman, it's upwards of 90 percent." She attributes that to the medical resources available in St. Louis; in areas with few plastic surgeons, reconstruction is more apt to be put off.
"Most of the breast surgeons at Siteman will encourage their patients to meet with us," she said. "Women can be overwhelmed with the diagnosis, and it's easy to get shuffled along the path."
Kara Kuhns, 34, is an elementary school speech pathologist from Arthur, Ill.; she and her husband, J.D., have two daughters, ages 5 and 2. Diagnosed in April 2012, Kuhns "figured from the get-go" that she would have reconstruction. "I just thought it would be best and easiest long-term on my self-esteem to have reconstruction. Whatever my doctors thought would be best is what we went with."
Kuhns had chemo all last summer and surgery in the fall, followed by radiation. She had her final reconstruction in May, and she's very happy with the results. "I think it looks very natural."
When Jane Feibel faced a mastectomy, she "roamed the Web for information about reconstruction. But, in the end, I saw no point in adding to the list of possible complications." She also feared that she would be "jarred by the sight of this alien thing on my chest every time I glanced in the mirror."
With "questionable densities" in the other breast, and in consultation with Margenthaler, her surgeon, Feibel had both removed. She has no regrets. She's symmetrical, her scars have healed well, and prosthetics, she said, are easy to wear. "Currently, the big mistake I make is going shopping and forgetting to wear my prosthetics." Her attitude toward the loss is "something like 'Too bad'."
In my case, a lumpectomy from the first cancer meant that I was already asymmetrical. My oncologist advised that radiation on that side made me a poor candidate for reconstruction.
Unable to face the possibility of a third diagnosis of breast cancer, I opted for a bilateral mastectomy and chose to do without reconstruction. I grieved the loss, but it was the right decision -- for me.
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