"Take two (or so) and call me in the morning (or next week or next month or next year)."

A large study that was just published shows that women with breast cancer who take aspirin are more likely to live longer and to not have a cancer recurrence than women who don't take aspirin.

Doctors at three Boston-area hospitals observed 4,164 female registered
nurses in the Nurses’ Health Study who were diagnosed with stages I, II, or III breast cancer between 1976 and 2002. They were observed until June 2006, or death, whichever came first.

The main outcome was breast cancer mortality risk according to number of days per week of aspirin use (0, 1, 2 to 5, or 6 to 7 days) first assessed at least 12 months after diagnosis and updated..There were 341 breast cancer deaths. Aspirin use was associated with a decreased risk of breast cancer death.

Full report here.

The study says of itself that it's unprecedented: Of several large prospective studies of the association of aspirin use with breast cancer incidence, only one found a protective association, whereas four others did not. The 10-year Women’s Health Study Trial found no effect of low-dose aspirin intake (100 mg every
other day) on breast cancer incidence among almost 40,000 women. However, meta-analyses of either NSAID [non-steroidal anti-inflammatory agents/analgesics such as aspirin, ibuprofen, and naproxen] or aspirin have found a 9% to 30% reduced risk of breast cancer incidence. Despite inconclusive evidence linking aspirin and breast cancer incidence, aspirin may improve survival through various mechanisms.

To our knowledge, this is the first study reporting a survival
advantage among women with breast cancer who take aspirin. Abundant
scientific evidence supports why aspirin may confer this advantage.
More than 2 million US women are living after a breast cancer
diagnosis6 Survival among women with breast cancer is variable, and
risks of dying of the disease are elevated even 10 or 15 years after
diagnosis.

How much aspirin is helpful? I kept reading reports about this and couldn't find the number of milligrams. I'm especially interested because I take 162 mg. for polycythemia vera. What a nice surprise it would be if something I take for one disease would help me survive another. Alas, the researchers admit: We
lack details on aspirin dose. If there is a dose response, the effect size in
the current study may be diminished because frequent aspirin users
may be more likely to be low-dose users attempting to prevent heart
disease. Confounding is always a limitation of observational studies.
We addressed this by adjusting for all relevant covariates and through
marginal structural models.

Another caveat: Our results may be generalizable only to longer term breast
cancer survivors (ie, only women who have lived long enough after
diagnosis to report aspirin use after diagnosis, which is approximately
4 years). Fortunately, almost 90% of women diagnosed with breast
cancer live at least 5 years. Thus, our findings have considerable
clinical importance.

"Take-home message," as they say in business: It couldn't hoit. Aspirin has relatively benign adverse effects compared with cancer chemotherapeutic drugs and may also prevent colon cancer, cardiovascular disease, and stroke.

One skeptic has already pointed out that this is an observational study that does not prove cause and effect.

Mammograms after Mastectomy and Breast Reconstruction - Are They Really Needed?

"Do I still need to have mammograms after my mastectomy and breast reconstruction?"

I'm asked this question quite often.

The truth is there's a lot of ongoing debate about this.

Some doctors feel that since there is no "natural" breast tissue left, there is no need to continue monitoring patients. I disagree with this strongly.

Breast cancer can come back after mastectomy - there's a 6.7% chance in fact. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.

Since the risk of breast cancer recurrence is a real one, surely we need to continue some sort of monitoring?

Self breast exam is a no-brainer. It's relatively easy to perform and it's dirt-cheap (free). The issue of mammograms is less clear-cut.

The appearance of the mammogram changes completely after breast reconstruction. Even if the breast looks very natural and similar to the way it did before the mastectomy on the outside, the inside of the breast is completely different.

Let's take the following example: a woman who undergoes a skin-sparing mastectomy and tissue (flap) reconstruction like a DIEP flap may look like she has natural breasts that have merely been "lifted". In reality her breast tissue has been completely replaced by tummy fat. Fat and breast tissue look completely different on mammograms so the post-reconstruction mammograms cannot be compared to any taken before the mastectomy. You're essentially starting from scratch as far as the mammograms go.

Some surgeons feel that patients should have 1 mammogram after the reconstruction has been completed just to get a new "baseline". If the regular self breast exams reveal anything new of concern then the mammogram can be repeated. At least now the new mammogram can be compared to the baseline mammogram.

Other breast surgeons take it a step further and recommend a baseline MRI once the reconstruction is completed instead of a mammogram. MRIs are much more sensitive (sometimes over sensitive though) and the information they provide is also more specific. Again, if self breast exam reveals a new area of concern in the future the MRI can be repeated to see if anything has changed.

The issues with MRIs are (1) the additional cost compared to a mammogram, and (2) sometimes they see things that really aren't there - for example, something that is benign is interpreted as worrisome. This in turn leads to further investigations and biopsies that may never have really been needed.

Yet one more viewpoint is that any new breast lumps that appear in the future are going to require a biopsy anyway so what is the point of getting a "baseline" MRI or mammogram at all? Tissue (flap) breast reconstructions can occasionally develop something called "fat necrosis". These are areas of fat in the new breast that become hard and create "lumps". While a biopsy may indeed be planned anyway, there is a lot to be said for the physician and patient knowing this "lump" has been there all along (on the MRI) and the chance of this representing a new cancer is extremely low. The additional peace of mind and information a baseline MRI provides in this situation alone warrants the test in some physicians' opinions.

What do I recommend? At least a mammogram 6 months after the breast reconstruction is completed to get a new baseline and regular self breast exams.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Please also Follow Dr C on Twitter.

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Breast Cancer Recurrence Not Related To Method Of Breast Reconstruction

One of my breast cancer patients called me today. She recently underwent bilateral mastectomies and immediate breast reconstruction with DIEP flaps. She recovered very well from the surgery but unfortunately her pathology results showed that she had cancer extending almost to the edge of the mastectomy specimen. The exact medical jargon used by the pathologist was.... "invasive carcinoma extending to 1mm from the margin". She also had DCIS (ductal carcinoma in situ) "extending to 0.2mm from the margin."

From a purist's perspective, these results still represent "clear margins". In other words, no tumor was found at the edge of the mastectomy specimen so there is no reason to believe there is any cancer left in my patient's breast. BUT, it's very close and that is certainly worrisome.

She called me today because she visited with her oncologist (cancer doc) and a radiation oncologist (cancer doc specializing in radiotherapy) and radiation therapy was recommended (in addition to the planned chemotherapy).

She explained to the radiation oncologist that she was worried the radiation therapy would ruin her DIEP flap reconstruction. She is right to be fearful of this - patients undergoing radiation therapy after an autologous reconstruction (ie a reconstruction using their own tissue) have a 28% risk of needing further surgery to correct asymmetry caused by the radiation changes (usually firming and shrinking) of the irradiated breast.

The response she received from the radiation oncologist baffled me (and is actually the reason behind this blogpost)...... "DIEP flap? What's a DIEP flap?.... if you'd had a TRAM flap then you wouldn't be needing radiation".

What?

This is a ridiculous statement. Let me clarify why...

This lady is being recommended radiation therapy as an insurance policy to decrease the risk of local recurrence (cancer coming back in the same breast). This is a consequence of her "near margins" which in turn are a result of the mastectomy specimen. Obviously the mastectomy was completed before the reconstruction was even started. If this lady had only had the mastectomy (without reconstruction) the margins would be the same. The breast reconstruction, and moreover, the type of breast reconstruction has absolutely nothing to do with it. The margins, the pathologist reading and the recommendation for radiation therapy would have been exactly the same whether reconstruction was performed or not.

So what's the take home message if you're considering breast reconstruction surgery? Choose whichever method of reconstruction is best for you. Your decision will not influence the likelihood of your cancer coming back in any way. The risk of cancer recurrence is related to the characteristics of the cancer itself and the mastectomy margins, not the method of reconstruction.

Dr C

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Dr Chrysopoulo is a board certified breast reconstruction surgeon specializing in DIEP flap breast reconstruction surgery. He and his partners perform over 350 DIEP flap procedures each year with a success rate of over 99%. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Cancer Reconstruction Blog.

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DIEP Flap Reconstruction And Breast Cancer Recurrence

Can DIEP flap breast reconstruction prevent detection of breast cancer recurrence? This is a very important issue that is often not discussed.

A handful of studies have shown that breast reconstruction (with any reconstructive technique) does not impact local recurrence or long term survival in patients with early breast cancer (stage I and II). The rate of local recurrence and length of survival is the same in patients with stage I and II disease whether they undergo immediate breast reconstruction (ie reconstruction at the same time as mastectomy) or not. For this reason most institutions (including ours) offer breast cancer patients with early disease immediate breast reconstruction whenever possible.

Patients diagnosed with advanced disease are more likely to be candidates for delayed breast reconstruction once they have undergone mastectomy, completed their cancer treatment and remained disease free for several months.

Breast reconstruction (with a DIEP flap or any other method) does not encourage or enhance breast cancer recurrence or shorten long term survival in any way.

Dr C

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including DIEP flap reconstruction. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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