Breast Reconstruction: It's a Personal Decision
Miller, Sarah Bryan, St Louis Post-Dispatch (MO)
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. …