Almost everyone knows at least one person whose life has been forever altered by breast cancer. Be it your mother or daughter, grandmother or sister, aunt or friend, or even yourself, the disease has had a lasting effect on almost all who have had to deal with this devastating diagnosis.
Breast cancer is the most common cause of cancer among US women and the second most common cause of cancer death in American women trailing only lung cancer. Approximately 1 in 8 women will develop breast cancer over their lifetime. However, while the incidence is high, the mortality rate is relatively low with an approximately 90 percent 5-year survival rate among women affected by breast cancer according to the National Cancer Institute and the Surveillance, Epidemiology, and End Results (SEER) registry. This has much to do with the increased awareness that has led to tremendous advances in both early detection and treatment. Increased awareness has led to better screening with mammography and breast exams.
Methods used to detect early breast cancer including MRI and core needle biopsies have allowed us to find cancers that would have been undetectable in the past. Treatment options now include multiple various combinations of medications, radiation and surgery. Multiple drug regimens have been used successfully involving various chemotherapy cocktails and anti-hormonal therapies. Radiation has been given successfully prior to surgery, after surgery or locally within the tumor cavity. Surgical options include mastectomy (complete removal of the breast) or a breast-conserving approach (lumpectomy) that removes only the tumor but requires the addition of radiation. Mastectomy itself has come a long way with most of these surgeries preserving the skin and it is even becoming more and more common to preserve the nipple and areola complex as well.
But what about life after breast cancer? With the increasing advancements in treatment, that possibility is now becoming a reality for more and more women.
There are more options than ever for restoration of the breast after treatment of the cancer and multiple factors for the patient to consider when choosing breast reconstruction. The first is the timing of breast reconstruction. This means deciding whether the reconstruction is done at the time of removal of the cancer or held off and done at a later time. As with the patient’s choice of lumpectomy and radiation vs. mastectomy, there are many factors to consider in this decision. Immediate reconstruction allows the plastic surgeon the ability to use the preserved breast skin in the reconstruction and the nipple/areola as well if this was saved. This will often provide the best cosmetic outcome for the breast reconstruction.
In addition, immediate reconstruction can have significant psychological benefits, as the new breast mound will be present either partially or completely at the end of the removal of the breast and minimize the time that the patient will be without a physical breast.
So what are the reasons that one would want to delay reconstruction? Interestingly, the same considerations for electing on immediate reconstruction could be the very reasons for choosing a delayed reconstruction, namely cosmetic and psychological benefits. In some situations, the cancer is locally advanced leaving no opportunity to preserve the skin or nipple and increasing the likelihood of requiring radiation after surgery. The need for post-operative radiation itself can be an indication to delay reconstruction of the breast depending on the type of reconstruction chosen as radiation can severely compromise the aesthetic outcome of the reconstruction. Psychologically, the diagnosis of breast cancer and the numerous decision-making options for treatment can understandably be overwhelming for some women. During this time, it is not uncommon for patients to be in a prolonged state of shock regarding their diagnosis and their focus is very appropriately targeted to removal of the cancer above all else. In these situations, it may be very appropriate to delay the reconstruction so that the patient can be more fully involved in the process of selecting the method of breast reconstruction that best fits the patients needs and desires after removal and eradication of the cancer has been addressed. The most important thing for women to realize is that both immediate and delayed reconstructions are viable options and excellent outcomes can be had from either method.
The options for the reconstruction itself have been evolving just as much as the treatments have. Classically, the two main options for reconstruction have been tissue expander/implant-based reconstruction and reconstruction using the patient’s own tissues without implants (a.k.a. autologous reconstruction). The third major option is typically reserved as a salvage procedure and involves the use of the back muscle (latissimus muscle flap) combined with an implant. Each of these options has had tremendous advancements in the last decade and there are even new options available for reconstruction in women who have elected partial mastectomy with radiation.
In 1996, the FDA lifted its effective ban on silicone breast implants and the implant options that women have had for breast reconstruction have been increasing ever since. The new highly cohesive silicone gels have allowed the development of anatomic “gummy bear” implants that retain their shape and can provide a more natural-looking breast reconstruction. Tissue expander/implant reconstruction has also been revolutionized with the introduction of Acellular Dermal Matrices (ADM) that have allowed improved coverage and position of the implant as well as faster expansion. In some cases a one-stage, direct-to-implant reconstruction has been made possible with the use of ADM.
Reconstruction techniques using the patient’s own tissue have undergone tremendous innovation as well. Classically, the TRAM flap using the patient’s abdominal tissue including skin, fat and muscle was tunneled under the skin and into the chest to reconstruct the breast. Although this was a technically straightforward procedure, it was wrought with numerous potential problems including contour deformities where the muscle was tunneled under the skin, partial loss of the reconstruction from poor blood supply, and abdominal hernia or bulge due to removal of the muscle. The modern version, known as the DIEP flap, essentially uses the fat and skin that would be removed with a tummy tuck and isolates the blood supply to this tissue in order to attach them to blood vessels in the chest using a surgical microscope. This technique improves the blood supply to the tissue while minimizing the chance of post-operative bulges and hernias but is technically demanding, as the blood vessels being isolated may be only 1-2 mm in size. These procedures will require an experienced plastic surgeon with advanced microsurgical skills but are becoming more and more common.
One of the techniques that has completely revolutionized the practice of plastic surgery is the refinement of fat grafting techniques. Excess fat can be harvested from the abdomen, flank, hips and thighs and has been grafted into the eyelids, cheeks, temples and buttocks and the breast is no exception. Fat grafting can be used after implants or DIEP flaps have been performed in order to balance out any asymmetries or contour problems. Fat grafting is also an excellent option for reconstruction after breast-conserving lumpectomy procedures that can sometimes have deformities after the completion of radiation therapy.
Although the options have increased and the psychosocial benefits of post-mastectomy breast reconstruction have been well documented, the rates of eligible patients receiving reconstruction have previously been reported as less than 20 percent. This low rate is even more surprising when you consider that in 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA) essentially making it a federal law that all insurance companies cover breast reconstruction after mastectomy for breast cancer. Although rates of breast reconstruction did rise after this legislation, the effect has not been the same across the country and one study grouped Nevada in the second to last tier of breast reconstruction utilization with only 39 to 50 percent of eligible, insured patients receiving reconstruction. Multiple racial, ethnic, socioeconomic, and geographic factors have been implicated in the extreme disparities seen among the variations in patients undergoing a breast reconstruction, but the aspect that is most concerning is the lack of patient education and knowledge about the options available to them. It has been reported that only 30 percent of women are informed about their options for breast reconstruction and a study out of the University of Michigan cited the two primary factors in women not undergoing breast reconstruction are: 1) the woman was not informed of her options, and 2) the woman was not referred to a breast reconstruction surgeon.
Breast cancer treatment continues to evolve and there have been numerous advances in the areas of surgery, chemotherapy, radiation and reconstruction. Adequate knowledge and understanding is essential as women have more of a role in choosing their treatment options.