Considering the Personal and Practical Decisions with Breast Reconstruction

When Jackie Calvert learned last year, at age 54, that she had ductal carcinoma in situ (DCIS) in her left breast and suspicious areas in her right breast, she opted for a bilateral mastectomy. With a family history of breast cancer and her own bout with melanoma, Calvert felt the more aggressive approach was her best option. To her, it seemed a no-brainer, especially after her surgeon explained that she could simultaneously have her breasts reconstructed using extra fat from her abdominal tissue.

“I knew immediately that was what I wanted to do,” says the mapmaker from Mississippi. “I can’t see what the purpose is of waiting. Who would want to go through that pain twice?”

Calvert, however, is in the distinct minority. Only about a third of women undergo immediate breast reconstruction after mastectomy, according to a 2011 analysis in the Annals of Surgical Oncology, with 11.5 percent delaying reconstructive surgery for months or years, and more than half of patients foregoing it altogether.

But while breast reconstruction rates have risen in the past dozen years, according to data presented at this past year’s San Antonio Breast Cancer Symposium, a hodge-podge of factors come into play as mastectomy patients decide whether or when to pursue having their breasts rebuilt–including age and body image along with more practical considerations such as other medical conditions, body shape and size, smoking history, insurance coverage and cancer subtype and treatments planned, particularly radiation. Choices only seem to multiply once women elect to reconstruct since newer surgical techniques now offer a veritable à la carte menu that includes using implants, their own tissue and, for some women, sparing the nipples.

“They basically become overwhelmed by the volume of information they’re exposed to,” says Frank DellaCroce, MD, co-founder of the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans. “There are so many different things they can analyze and pick apart; it becomes a bit of an informational storm to them. I walk them through what each of the options carries in terms of recovery and lifestyle, and all variables eventually need to be tailored to that person.”

Not informing women that they have options is the first obstacle, DellaCroce says, since many doctors don’t bring up reconstruction with mastectomy patients during their initial consultations. His perception is backed by data: 70 percent of breast cancer patients eligible for reconstruction aren’t informed of the options available to them, according to the American Society of Plastic Surgeons (ASPS).

But most women faced with a breast cancer diagnosis don’t automatically think about losing their breasts–they worry about losing their life, says Andrea Pusic, MD, a plastic and reconstruction surgeon at Memorial Sloan-Kettering Cancer Center in New York.

“The only thing they’re thinking about is surviving their cancer,” Pusic says. “One of the challenges of breast reconstruction is helping a woman to envision where she’ll be two, five or 10 years out. They feel they can’t even give themselves permission to think about it, like it’s being frivolous to some extent. But it’s critical because most women with breast cancer do well and survive.”

Liz Anderson was nearly done with radiation therapy for her stage 3 breast cancer in 2009, when a radiologist filling in for hers mentioned it was possible to re-create her breasts using tissue taken from the abdomen, buttocks or back, known as autologous reconstruction. After her bilateral mastectomy and six rounds of chemotherapy, the fitness instructor from Naples, Fla., had been unhappily wearing breast prostheses.

Now 49, Anderson gained more than 20 pounds on her thin frame to offer the surgeon enough tissue to form C cups, one cup size smaller than she was before her mastectomy.

“I felt too young to never have breasts again,” says Anderson, who had realistic-looking nipples tattooed onto her reconstructed pair. “Once I got the tattoos, I felt I was back. Part of my stubbornness was getting back what cancer took from me. I look like a normal woman.”

[Read and comment on editor Kathy LaTour's decision on reconstruction a year after cancer treatment in "Reconstruction: shopping for a new boob]

Looking like their former selves–which DellaCroce describes as an “effort to retain your body as you know it” – is just one of the factors at play when breast cancer patients contemplate reconstruction, though certainly not a consideration for all women.

Jackie Dillard, of Fairburn, Ga., wasn’t concerned with reconstruction after being diagnosed with stage 2B breast cancer in 2001. “At the time of my mastectomy, I was only concerned with getting rid of the cancer.” After treatment, she says she thought about it briefly, but decided that ultimately, she didn’t want to go through more surgeries. “Breast or no breast, I am still a woman,” she says, more than 10 years after her initial diagnosis. “All that matters is how I feel on the inside, not how I look on the outside. I wear my breast form, and not until I get undressed do I see that I have only one breast.”

[Read and comment on if reconstruction or not was the right decision for you in "Reconstruction decisions"]

What questions should women ask when deciding on reconstruction?

Does my age matter? Not much. “Age used to be a factor, and now we’re finding it shouldn’t be,” Pusic says. “Obviously we don’t want to do an eight-hour surgery on a woman who’s 80 years old, but implant reconstruction in a 65- or 70-year-old woman only adds (a short time) to a mastectomy operation.”

Should I use implants or my own tissue? Breast implants are used in nearly two-thirds of reconstructions compared with about a third of plastic surgery skin flaps, according to a study published in the ASPS journal, Plastic and Reconstructive Surgery, but both procedures have pluses and minuses. Implant surgery is shorter—roughly two to three hours, compared with up to 10 hours for autologous reconstruction—and confines scarring to the chest region instead of multiple areas. Recovery time is also shorter, DellaCroce notes. But implants, whether silicone or saline, may need replacing after about 15 years while autologous surgery is typically one-and-done, and this tissue gains and loses weight with a woman’s natural fluctuations. Autologous surgery complications are also higher in patients with microvascular compromise, as may be seen in smokers or patients with diabetes.

How do my cancer type and treatment affect my choices? Both the stage of cancer and its location within the breast impact reconstruction options, as does a woman’s overall health status. Radiation therapy can damage skin or create a capsule of scar tissue around artificial implants, making autologous reconstruction a better option for many of these patients, DellaCroce says. If tumors aren’t located near the nipple, sometimes it can be spared and incorporated into the reconstruction, but the final outcome is as singular as each patient. “It all starts with big-picture items and then gets filtered down through the details,” he says.

What are the potential complications? With any surgery, there is a possibility of complications. Ask about potential side effects, which may include infection, pain, skin numbness and in the case of implants, rupture and capsular contracture, when the skin tightens around the implant and forms an unnatural shape to the breast.

Will my insurance cover reconstruction? Yes, at least partially. The Women’s Health and Cancer Rights Act of 1998 mandated coverage of breast reconstruction following mastectomy, but the percentage covered varies with each carrier. And uninsured women may find funding sources for the surgery through university hospitals, research centers or charitable foundations, DellaCroce says.

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