Photo source: Thinkstock
Co-authored by Paul Taylor, Personal Health Navigator at Sunnybrook
Question: I have recently been diagnosed with breast cancer. I don't know what all my treatments will be yet, but I expect I will be losing part of my breast. I'm in my mid-50s. What options will I have for reconstructive surgery?
Answer: Most women would be considered candidates for some type of reconstructive surgery following either a lumpectomy or a mastectomy.
In fact, there are only a few conditions that would make a woman ineligible for such a procedure, says Dr. Laura Snell, a plastic and reconstructive surgeon at Sunnybrook Health Sciences Centre.
For instance, some patients who have numerous health problems may not be able to undergo a general anaesthetic without a great deal of risk. So it may be unwise for them to be having extra surgeries as part of their cancer treatment.
If you're in good health -- aside from having cancer, of course -- then reconstructive surgery will likely be an option.
Reconstructive procedures are divided into three categories:
- Saline and silicone implants are used to replace the breast(s) surgically removed in either a single or double mastectomy;
- The patient's own muscle or fat tissue -- usually from the stomach or back -- is moved or rearranged to fill in the gaps left by a lumpectomy or to create a new breast; and
- A combination of the patient's own tissue and implant(s) are used to form a new breast.
What works best for you will depend on several factors including the extent of your cancer, your breast size and body shape and whether you have extra tissue to spare.
At Sunnybrook's Odette Cancer Centre, patients are offered reconstructive surgery as part of their cancer treatment program.
"We are endeavoring, in conjunction with the breast surgeons, to see as many women as we can who would be potential candidates for immediate breast reconstruction at the time of their initial breast cancer diagnosis," says Dr. Snell.
A lumpectomy, which involves the removal of the tumour and a surrounding margin of tissue, is generally considered to be a less radical procedure than a mastectomy that eliminates the entire breast.
But a lumpectomy can sometimes be very disfiguring, too. Depending on how much tissue is removed, one breast may end up being significantly smaller than the other.
By working with the breast surgeon -- who is responsible for removing the tumour -- the plastic surgeon can make recommendations that will lead to a better outcome aesthetically.
"We can help the breast surgeon design the lumpectomy incision and help move tissue around at the time of the lumpectomy to minimize the defects afterwards," says Dr. Snell.
In planning the reconstructive work, the doctors also have to take into account the other cancer treatments the patient is expected to receive, says Dr. Frances Wright, a breast cancer surgeon at Sunnybrook.
Radiation therapy, she explains, can cause the tissue surrounding an implant to contract, thereby deforming the breast. So if a patient needs radiation therapy following the removal of the tumour, and has opted to have an implant, then it's best to postpone an implant-based reconstruction.
"Sometimes patients, who are known to require radiation after a mastectomy, can have reconstruction with their own tissue at the same time as the surgery," adds Dr. Wright. "However, these are complicated decisions and a patient would need to consult with both a surgical oncologist and a plastic surgeon to make the best choice for her."
For some women, breast reconstruction can involve multiple procedures and take up to a year to complete.
It's very important for patients to have realistic expectations about what they are going to look like afterwards, says Barbara Fitzgerald, an Advanced Practice Nurse at Sunnybrook.
"We cannot replace exactly what was taken away," she explains. You will be left with permanent scars, and the reconstructed breast following a mastectomy will lack normal feelings and sensations. And it's important to keep in mind that there is a risk of complications, which may require additional corrective surgeries.
Even so, "most women are happy with the outcome because they look more natural in their clothes," says Ms. Fitzgerald. In other words, you wouldn't know a woman has had breast cancer if you saw her on the street for the first time. That means reconstructive surgery is one strategy that can help women resume a more normal life.
Despite these advantages, relatively few Canadian breast cancer patients -- only about 7 to 10 per cent -- proceed with the restorative work. Most of these operations involve patients who have had a mastectomy, rather than a lumpectomy.
Some women are simply not interested. Or, they feel overwhelmed by their cancer diagnosis and don't want to add another layer of complexity to their treatment. It's perfectly fine to delay these decisions because reconstructive surgery can be done at a later date -- even years after the original cancer surgery, says Dr. Wright.
But for many women the issue they face is a lack of timely access to plastic surgeons whom are trained to perform this specialized work.
"There are a lot more general surgeons doing mastectomies than there are plastic surgeons doing breast reconstructions," says Dr. Snell.
Indeed, not all cancer centres try to co-ordinate cancer treatments with breast reconstruction. So where you live in Canada can affect how long you will have to wait for the services of a plastic surgeon.
On a positive note, breast reconstruction is covered by the provincial health insurance plans.
There is also a very informative website - www.breastreconstructioncanada.com - that provides an overview of the different types of procedures and lists plastic surgeons who specialize in breast reconstruction.
It was created by the Canadian Collaboration on Breast Reconstruction, which includes more than 100 physicians from across the country.
The website has a useful locator tool. Just type in where you live and a particular procedure you want -- and up pops a list of plastic surgeons who do the operation in your geographic area.
Dr. Snell says there are some common misconceptions about breast reconstruction -- even within the medical community. "Some people wrongly assume it could interfere with the detection of a re-occurrence of the cancer," she says. Furthermore, silicone breast implants got a bad rap in the 1990s when a few studies linked them to autoimmune diseases and an increased cancer risk. Subsequent research has essentially exonerated the implants.
"There is a lot of misinformation out there that may discourage women from moving forward with breast reconstruction," said Dr. Snell.
But obviously that is not an issue for you. I would encourage you to talk to your cancer team about it and check out the website.
Overall, the procedures can be extremely worthwhile for a significant number of women who are now being cured of breast cancer.
"It's a survivable disease," says Dr. Snell. "Having breast reconstruction really helps with long-term satisfaction, being able to move on, and being able to get past their diagnosis."
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