Breast Reconstruction Report: "I wanted to heal my way"

By Lisa Bernhard

I was 29 years old when my gray-haired surgeon looked at me from across his desk and said, "I'd recommend a mastectomy." My dad, seated to my left, exhaled hard. To my right, my mom sat in silence. Family history had repeated itself: My grandmother underwent a mastectomy at age 39. Now it would be me. But in the four days since my diagnosis, I had researched and stumbled upon a choice my grandmother never had.

"It's OK," I said to my dad. "They can rebuild me."

They did. In one nine-hour procedure, a cancer surgeon performed a skin-sparing mastectomy, removing the nipple and tissue inside my right breast but leaving most of the skin intact. Then a plastic surgeon performed a free-flap reconstruction, extracting a portion of my stomach skin and fat and microscopically reconnecting it to my chest. Later, he reconstructed the nipple. The result was a breast that looks and feels like...my breast.

In the 14 years since, my reconstructed chest has seen me through highs and lows: confident in an evening gown while reporting from the Oscars as a TV correspondent; sorrowful, at times, when standing naked under bright bathroom lights, the faint scars tracing my areola reminders of invading disease and scalpels. Yearly screenings send my heart pounding, but my surgery has helped me be hopeful about the future.

Of course, some women don't want any kind of reconstruction, sometimes due to health reasons or as a matter of preference. But women who do choose it report significant, lasting psychological benefits, in a way that transcends physical beauty, according to a study by Amy K. Alderman, M.D., assistant professor of plastic surgery at the University of Michigan Medical School in Ann Arbor. "Women tell me they feel whole again and more able to put cancer behind them," she explains.

Which is why I'm alarmed that many women don't know that options like the one I selected exist. Nearly 70 percent of women eligible for reconstruction aren't informed of their reconstructive options, according to a 2007 study by Dr. Alderman. Almost 65 percent of general surgeons said they believe patients lack interest in reconstruction, and less than one in four consistently refers breast cancer patients to plastic surgeons.

Meanwhile, plastic surgeons often limit the time they devote to cancer patients, because they tend to lose money treating them. Insurance reimbursements—which are roughly based on what Medicare pays—are paltry. In the case of free-flap surgery, plastic surgeons can charge $7,000 to $25,000 per breast; the average Medicare reimbursement in 2007 was $1,737. As a result, some doctors won't accept insurance for reconstructive surgeries, forcing patients to pay out of pocket. Others steer patients toward more profitable types of reconstruction, regardless of what's best medically, says Mark Sultan, M.D., my reconstructive surgeon and chief of the division of plastic surgery at St. Luke's-Roosevelt Hospital Center and Beth Israel Medical Center in New York City. Insurers reimburse implant reconstruction at roughly the same level as a flap, but surgery takes only about an hour. "Doctors may think, Why do a six-hour operation when I am paid the same amount for a one-hour implant?" Dr. Sultan says. "They may convince themselves, consciously or unconsciously, that the patient is a better candidate for an implant."



Comment by Dr C:

I completely agree with Dr Sultan and I strongly encourage all women considering breast reconstruction to research all their reconstructive options. Unfortunately, some patients will have to consider traveling for some of the more advanced procedures. A major consideration for most people is obviously cost. Patients must be aware of the practice of balance billing which can add thousands of dollars to the out-of-pocket expenses.


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Keep up to date with the latest news in breast reconstruction at The Breast Cancer Reconstruction Blog. Also follow us on Twitter!

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Breast Reconstruction After Mastectomy - Dr Chrysopoulo Radio Interview

It was an absolute pleasure to talk to DeLeon and Travis on "DeLeon Dialogue" last night.

Breast cancer survivor DeLeon and cervical cancer survivor Travis talk frankly with their guests about quality of life as cancer survivors in remission. They discuss side effects, spirituality, mastectomy, sexuality, health and wellness, self-esteem, food, exercise, relationships, and everything else in between.

Last night the one-hour show was about "breast reconstruction after mastectomy". We managed to cover a lot of ground - we talked about the various cutting edge breast reconstruction options currently available, breast implants, the impact of radiation therapy on reconstruction, recovery from surgery, and insurance coverage for reconstruction. Please click on the link below to listen to the show:

Breast Reconstruction after Mastectomy - Dr Chrysopoulo on DeLeon Dialogue

I hope you enjoy the show as much as I did!

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 (including DIEP flap and TUG flap procedures). PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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When is Prophylactic Mastectomy The Right Choice?

Having breast cancer in one breast increases a woman's chances of getting breast cancer in the second breast at some point in her lifetime. A study in the March issue of Cancer addresses a question which women facing mastectomy for breast cancer have been asking doctors for years.... should I have my other ("good") breast removed as well to decrease my risk of future breast cancer in the other breast? Here's the study abstract....

"Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy."
Min Yi, Funda Meric-Bernstam, Lavinia P. Middleton, et al. CANCER Print Issue Date: March 1, 2009

BACKGROUND:
Although contralateral prophylactic mastectomy (CPM) reduced the risk of contralateral breast cancer in unilateral breast cancer patients, it was difficult to predict which patients were most likely to benefit from the procedure. The objective of this study was to identify the clinicopathologic factors that predict contralateral breast cancer and thereby inform decisions regarding performing CPM in unilateral breast cancer patients.

METHODS:
A total of 542 unilateral breast cancer patients who underwent CPM at The University of Texas M. D. Anderson Cancer Center from January 2000 to April 2007 were included in the current study. A logistic regression analysis was used to identify clinicopathologic factors that predict contralateral breast cancer.

RESULTS:
Of the 542 patients included in this study, 25 (5%) had an occult malignancy in the contralateral breast. Eighty-two patients (15%) had moderate-risk to high-risk histologic findings identified at final pathologic evaluation of the contralateral breast. Multivariate analysis revealed that 3 independent factors predicted malignancy in the contralateral breast: an ipsilateral invasive lobular histology, an ipsilateral multicentric tumor, and a 5-year Gail risk 1.67%. Multivariate analysis also revealed that an age 50 years at the time of the initial cancer diagnosis and an additional ipsilateral moderate-risk to high-risk pathology were independent predictors of moderate-risk to high-risk histologic findings in the contralateral breast.

CONCLUSIONS:
The findings indicated that CPM may be a rational choice for breast cancer patients who have a 5-year Gail risk 1.67%, an additional ipsilateral moderate-risk to high-risk pathology, an ipsilateral multicentric tumor, or an ipsilateral tumor of invasive lobular histology.

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So what does all this mean?

This study basically concludes that prophylactic (ie preventive) mastectomy should be recommended to breast cancer patients in the following situations:

1) the breast cancer is particularly aggressive or invasive

2) the biopsy pathology report shows high risk histology (such as "invasive lobular" disease)

3) there are multiple tumors in the same breast

4) a 5-year Gail risk of at least 1.67 - The "Gail risk" assesses a woman's risk of developing breast cancer by looking at a number of health factors including her medical history, race, age and more.

5) age 50 or older at the time of the first breast cancer diagnosis

This study is helpful. I'd like to expand a little on the effect age has on risk of future disease. Many doctors (including myself) recommend prophylactic mastectomy to young women, particularly if they have a family history of breast cancer, as these women have the highest overall risk of getting another cancer in their lifetime. Previous studies have shown that breast cancer patients have close to a 1% risk of another cancer per year. This risk is cumulative, in other words, it adds up: 1 % risk after 1 year, 10% risk after 10 years, 30% after 30 years, and so on. This cumulative risk is important to remember.

While I applaud this study and think it's results are very useful, I also think it is imperative that doctors remember the primary indication for prophylactic mastectomy: the patient's wishes. Breast cancer is such a devastating disease both physically and emotionally. We can educate our patients all we want about study results but we must not forget the erosive nature of anxiety over the possibility of a second breast cancer in the future. If one of my patients wants a prophylactic mastectomy even after discussing the studies, that's good enough for me.

Dr C

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

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Breast Reconstruction Surgery - Part I - Tissue Expanders, Breast Implants and Alloderm

This posting is the first of a 3-part series on breast reconstructive surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.

Every woman has a right to breast reconstruction. This has now actually become a federal mandate and insurance companies are required to pay for all types of breast reconstruction by law. Having said that it is also important to remember that it’s not up to the health insuranc carrier to decide which reconstruction a patient receives. That’s determined by the patient and her surgeons.

Breast reconstruction is not a form of cosmetic surgery – it restores something that nature has provided but cancer has taken away. There is also no age limit – as long as there are no medical conditions that render the surgery unsafe and the breast cancer is diagnosed at an early enough stage, most women are candidates.

Breast reconstruction can be performed as an “immediate” or “delayed” procedure. As the term implies, immediate reconstruction is performed immediately after the mastectomy while the patient is still under anesthesia. Once the general surgeon has completed the mastectomy the plastic surgeon begins creating the new breast. Advantages of this approach include the option of preserving most of the breast skin (“skin-sparing mastectomy”) and a shorter scar. The patient also wakes up “complete” and avoids the experience of a flat chest. Immediate reconstruction generally provides far superior cosmetic results.

Delayed reconstruction generally takes place several months following mastectomy. Patients required to undergo radiation after mastectomy may be advised to delay reconstruction in order to achieve the best results. This delay may last several months in order to allow the tissues to recover as much as possible from the radiotherapy.

There are several reconstructive options for women to choose from, ranging from breast implants to “autologous” techniques using the patient's own tissue to recreate a more “natural”, warm, soft breast. The nipple and areola can also be recreated.

Tissue Expanders and Breast Implant Reconstruction

This is the most common method of reconstructive breast surgery currently being used in the United States. Most surgeons perform this is a two-stage procedure. The tissue expander is essentially a temporary breast implant which can be placed either at the same time as the mastectomy or after the mastectomy has healed. The expander is used to stretch the skin envelope and recreate the size of breast the patient wants. The expander is ultimately replaced by a permanent implant (saline or silicone) at a separate procedure several months later.

Some patients undergoing immediate breast reconstruction are candidates for one-step breast implant reconstruction whereby a permanent implant is inserted at the time of the mastectomy and the patient avoids going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and Alloderm (a cadaveric acellular dermal graft). This is specially treated skin from a cadaver that is used to provide a sling and coverage of the lower part of the implant.

Two types of implants are available to patients: saline and silicone. There are many opinions regarding both types of implants and it is advised that you speak with your surgeon as to which implant would be best for you. Patients who undergo implant reconstruction should be aware that their breast implants may need to be replaced at a future date.

Implant reconstruction can be the best option for some patients. However, tissue expanders and implants can be fraught with complications long-term, particularly if the patient has had or is going to have radiation therapy as part of her cancer treatments. For these reasons, many surgeons and patients prefer autologous reconstruction, i.e. reconstruction using the patient's own tissue taken from another part of the body. These will be discussed in upcoming posts.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in reconstructive breast surgery after mastectomy. Techniques offered include Alloderm one-step reconstruction and DIEP flap reconstruction. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction Surgery - Part II - Muscle Flap Reconstruction

Women interested in breast reconstruction after mastectomy have several reconstruction options to choose from. In Part I of this series we discussed tissue expanders, breast implants and Alloderm.

Though implant reconstruction remains the most common method of breast reconstruction in the US, many women are now steering away from this option, opting instead to use their own tissue for more “natural” results. Muscle flaps have, until fairly recently, been the only choice available for these tissue reconstructions. The most commonly offered muscle flaps are the latissimus and TRAM flap procedures.

Latissimus Dorsi Flap:

The latissimus procedure uses muscle from the back of the shoulder blade which is brought around to the breast mound to help create a new breast. During the procedure a section of skin, fat and muscle is detached from the back and brought to the breast area.

Many patients also need a tissue expander placed under the muscle flap in order to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line.

Patients will have a scar on their back shoulder region that can sometimes be seen through a tank top, swimsuit or sundress. The upper back can be numb or sore for a few following this procedure until the nerves grow back and the incisions are completely healed.

Women who are very active in sports should know that this procedure can reduce ability to participate in activities like golf, climbing, swimming, or tennis.

TRAM (Transverse Rectus Abdominis Myocutaneous) Flap:

The TRAM flap was the first procedure to describe use of one of the rectus abdominis muscles (sit-up muscles) for breast reconstruction. This procedure begins with an incision from hip to hip rather like a “tummy-tuck”.

A "flap" of skin, fat and one of the patient's abdominal muscles is typically tunneled under the skin to the chest to create a new breast. This is known as a pedicled TRAM flap. Recovery from the TRAM flap procedure can be difficult and painful and there is a risk of abdominal bulging (or “pooching”) and even hernia. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%) which most active patients will notice.

In cases where both breasts are being reconstructed, both abdominal muscles are sacrificed and transferred to the chest (one for each breast). The loss of abdominal strength in these situations is far greater and very significant.

Over the years and with the introduction of microsurgery, the procedure has evolved several times with each modification preserving more and more abdominal muscle. This has made postoperative recovery a little easier and has decreased the potential for abdominal complications somewhat.

The latest evolution in breast reconstruction is  “perforator flap surgery”. These techniques use skin and fat from various parts of the body. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. These techniques will be discussed in Part III of this breast reconstruction series.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction after mastectomy including the DIEP flap and Alloderm one-step procedures. In-network for most US insurance plans. Toll Free (800) 692-5565. Latest news in breast reconstruction surgery and research available at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction Surgery - Part III - Perforator Flap Reconstruction

The ideal breast reconstruction technique is one which allows reconstruction of a “natural”, warm, soft breast with the least impact on the patient’s body. While breast reconstruction with stem cells may not be too far off, until it becomes a reality we are limited to using the patient’s own tissue to achieve these goals. As discussed in the previous posts in this breast reconstruction series, until fairly recently the only “tissue reconstruction” options involved sacrificing muscle. This made recovery from the surgery difficult and painful, not to mention the risk of long-term muscle function loss and weakness.

Perforator flap techniques use skin and fat from various parts of the body. All muscles are preserved. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. The downside to these procedures is that they are technically much more demanding than other breast reconstruction techniques and require microsurgical expertise. For this reason they are not offered by many plastic surgeons and patients must be prepared to travel when choosing these procedures.

DIEP (Deep Inferior Epigastric Perforator) Flap

The DIEP flap is the latest evolution of the TRAM flap (discussed in Part II) and represents today's gold standard in breast reconstruction. The DIEP flap procedure is similar to the TRAM flap but only requires the removal of skin and fat. NO MUSCLE is sacrificed. The blood vessels required to keep the tissue alive lay just beneath the abdominal muscle. Therefore, a small incision is made in the abdominal muscle in order to dissect the vessels and microsurgery is required to reattach the blood vessels to the chest area.

Even though an incision is made in the abdominal muscle NO abdominal muscle is removed or transferred to the breast in the DIEP flap procedure. As a result, patients do not have to sacrifice their abdominal strength and they experience less pain and a much quicker recovery. The risk of abdominal bulging and hernia is also very small.

The DIEP flap was first described in the early 1990's but has remained much less popular than the TRAM flap among plastic surgeons, presumably because of the increased complexity and difficulty of the procedure compared to the TRAM.

So the advantages of the DIEP flap are multiple: it uses living tissue to recreate a breast that often looks and feels like a normal breast; abdominal strength is not affected; the risk of bulging or hernias is significantly reduced; and, like the TRAM flap, the patient benefits from a simultaneous “tummy-tuck”.

The DIEP flap is a very technically demanding operation but the benefits are tremendous for the patient, especially when performed at the same time as a skin-sparing mastectomy.

SIEA (Superficial Inferior Epigastric Artery) Flap

The SIEA flap procedure is very similar to the DIEP flap procedure. The main difference between the SIEA and DIEP is the artery used for blood flow supply to the reconstructed breast. The SIEA arteries are generally found in the fatty tissue just below skin.

As in the DIEP the SIEA flap reconstruction does not sacrifice the abdominal muscle and only uses the patient's skin and fat to reconstruct the breast. While the SIEA flap procedure is similar to the DIEP it is used less frequently since less than 20% of patients have the anatomy required to allow this procedure.

GAP (Gluteal Artery Perforator) Flap

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for the GAP flap. This procedure uses excess skin and fat from the gluteal or buttock region. Fat and skin from either the upper or lower buttock region can be used and microsurgically transplanted to the chest.

Once again, no muscle is sacrificed. Incisions can generally be hidden by most underwear. If a patient requires a bilateral reconstruction with GAP flaps most surgeons prefer to only perform one side at a time. It is important to discuss this possibility with your surgeon.

Advantages of the GAP flap include: a scar that is generally hidden with underwear or swimsuits, and no loss of muscle function or strength.

Other Breast Reconstruction Options:

TUG (Transverse Upper Gracilis) Flap

Like the GAP flap, the TUG flap is an option in cases where there is not enough lower abdominal tissue to reconstruct the breast(s). The TUG procedure uses the upper part of the inner thigh; skin, fat and a small amount of muscle are disconnected and transferred to the chest to create the new breast. The patient benefits from a simultaneous inner thigh lift. Once again, this procedure is not widely available due to its complexity and need for microsurgical expertise.

It is important to realize that whichever method of reconstruction is used, the vast majority of women will require 2 or even 3 procedures for the optimal cosmetic result. Each procedure is typically separated by several weeks. The entire reconstructive process, regardless of the method of reconstruction, can therefore take several months to complete. However, breast reconstruction does NOT typically complicate or delay cancer treatment such as chemotherapy.

With all this in mind and also remembering the superior cosmetic results associated with immediate breast reconstruction (reconstruction performed at the same time as mastectomy), it is recommended that women discuss their reconstructive options with a plastic surgeon specializing in breast reconstruction before undergoing mastectomy whenever possible.

For more information about breast reconstruction options please visit www.prma-Enhance.com. For the latest news and developments in breast reconstruction please also visit The Breast Cancer Reconstruction Blog.

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Dr Chrysopoulo, board certified plastic surgeon, PRMA Plastic Surgery, San Antonio, TX. Specializing in breast reconstruction surgery after mastectomy for breast cancer. Over 350 DIEP flaps performed yearly. In-network for most US insurance plans. Toll Free (800) 692-5565. www.prma-Enhance.com. Latest breast reconstruction news available at The Breast Cancer Reconstruction Blog.

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Breast Reconstruction With Tissue Much Safer Than Implants When Radiation Planned After Mastectomy

A study published in the November issue of the International Journal of Radiation Oncology*Biology*Physics examined the effect of radiation therapy on different methods of immediate breast reconstruction surgery. For breast cancer patients who receive radiation therapy after a mastectomy and immediate breast reconstruction, autologous tissue reconstruction (ie reconstruction using their own tissue) provides fewer long-term complications and superior cosmetic results than breast reconstruction with a tissue expander and subsequent breast implant.

Many women choose to undergo breast reconstruction surgery at the same time as their mastectomy procedure (under the same anesthetic). This avoids many of the psycho-social issues women face when dealing with a flat chest after mastectomy alone. However, frequently radiation can negatively affect the outcome of reconstruction and increase the risk of long-term complications.

Radiation therapy is increasingly becoming the standard of care for high-risk breast cancer patients after mastectomy in an attempt to decrease local cancer recurrence. However, this can cause a problem for both patients and their radiation oncologists.

Researchers at the Department of Radiation Oncology at Long Island Radiation Therapy in Garden City, N.Y., the Department of Surgery at Long Island Jewish Hospital in New Hyde Park, N.Y., the Department of Surgery at North Shore University Hospital in Manhasset, N.Y., and the Department of Surgery at Winthrop University Hospital in Mineola, N.Y., looked at whether the type of reconstruction performed in women receiving radiation after a mastectomy had an impact on their long-term outcomes.

Two general types of breast reconstruction are available for patients facing mastectomy for breast cancer: autologous tissue reconstruction utilizing the patient's own tissue (eg DIEP flap, GAP flap, TRAM flap, or latissimus flap) transferred to the chest to recreate the breast(s); and tissue expander/implant reconstruction which involves placement of an inflatable tissue expander (temporary saline implant) and exchange for a permanent implant (saline or silicone) at a separate procedure later on.

This study involved the largest reported series of patients who sequentially underwent mastectomy, immediate reconstruction and postmastectomy radiation therapy. Ninety-two patients were observed for a period of 38 months following breast reconstruction and radiation therapy.

Researchers found that autologous breast reconstruction is better tolerated by breast cancer patients because it is associated with fewer long-term complications and better cosmetic results than tissue expander/implant reconstruction.

None of the 23 patients reconstructed with their own tissue required further surgery while 33% of tissue expander/implant patients needed surgery to correct a problem with their reconstruction. Eighty-three percent of autologous reconstruction patients reported acceptable cosmetic results, as opposed to only 54% of implant patients.

"This study is useful for patients who are candidates for either [method of reconstruction] and are making a decision with regards to reconstruction technique," Jigna Jhaveri, M.D., lead author of the study and a radiation oncologist at Advanced Radiation Centers of New York in Hauppauge, N.Y., said. "Our study provides evidence that patients who undergo autologous tissue reconstruction and radiation therapy have fewer long term complications and better cosmetic outcomes than those who undergo tissue expander/implant reconstruction and radiation therapy."

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Here's my take....

While some plastic surgeons will disagree with this statement I strongly believe that breast implants and radiation therapy do not get along (at all). I feel the complication rate in implant-reconstructed women receiving radiation therapy is very high, particularly long-term. The handful of women that "do fine" in the short-term will very frequently end up with hard, uncomfortable breasts as the irradiated tissue firms-up over time and squeezes down on the implant. In my opinion the re-operation rate is too high for tissue expander/implant reconstruction to be offered as a routine option when radiation is on the table. This study confirms that breast reconstruction using the patient's own tissue is far safer than tissue expander/implant reconstruction in women facing radiation therapy after mastectomy.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy, particularly advanced perforator flap techniques such as the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following The Breast Cancer Reconstruction Blog.

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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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Avoiding Denervation of Abdominal Muscles during DIEP Flap Breast Reconstruction Surgery

The following interesting article was published in the "Plastic and Reconstructive Surgery" journal this month.....

Avoiding Denervation of Rectus Abdominis in DIEP Flap Harvest II: An Intraoperative Assessment of the Nerves to Rectus
by Rozen W, Ashton M, Kiil B, et al.
Plastic and Reconstructive Surgery:Volume 122(5) November 2008 pp 1321-1325.

Background: The deep inferior epigastric artery perforator (DIEP) flap aims to reduce donor-site morbidity by minimizing rectus muscle damage; however, damage to motor nerves during perforator dissection may denervate rectus muscle. Although cadaveric research has demonstrated that individual nerves do not arise from single spinal cord segments and are not distributed segmentally, the functional distribution of individual nerves remains unknown. Using intraoperative nerve stimulation, the current study describes the motor distribution of individual nerves supplying the rectus abdominis, providing a guide to nerve dissection during DIEP flap harvest.

Methods: Twenty rectus abdominis muscles in 17 patients undergoing reconstructive surgery involving rectus abdominis (DIEP, transverse rectus abdominis musculocutaneous, or vertical rectus abdominis musculocutaneous flaps) underwent intraoperative stimulation of nerves innervating the infraumbilical segment of the rectus. Nerve course and extent of rectus muscle contraction were recorded.

Results: In each case, three to seven nerves entered the infraumbilical segment of the rectus abdominis. Small nerves (type 1) innervated small longitudinal strips of rectus muscle, rather than transverse strips as previously described. There was significant overlap between adjacent type 1 nerves. In 18 of 20 cases, a single large nerve (type 2) at the level of the arcuate line supplied the entire width and length of rectus muscle.

Conclusions: Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.

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Here's my take....

The long and the short of it is that for DIEP flap surgery to be considered successful several things need to happen (in my opinion):

1) the tissue (flap) transferred to the chest to create the new breast must survive. ie the new breast must live. Obvious.
2) the patient must not suffer any ill-effects from removal of the tissue ("flap") from the abdomen. This is what we call in the trade "donor-site morbidity". Abdominal bulging, hernia and significant muscle strength loss fall in this category.
3) the patient must be happy.

Number 1 is obvious.

This article addresses number 2. Ideally, other than the scar, the patient's abdomen must recover completely from the surgery and suffer no long-term problems for the surgery to be deemed a full success.

It does not matter how much muscle is left behind if the nerves supplying it have all been cut. A muscle without a healthy nerve supply will lose it's tone, strength and function. If the DIEP surgeon does not take great care to identify and preserve the majority of the nerves supplying the abdominal muscle then the benefits of the DIEP are potentially lost.

I feel it is important for me to make an additional point..... I'm going to take it for granted that you have chosen an experienced DIEP flap surgeon. I have heard of some patients (indeed some of mine too) entering the consultation with their DIEP flap surgeon having already decided they will be getting a DIEP flap and nothing else. This is a dangerous game to play and I'm going to explain why.

I'd like to think that most breast reconstruction surgeons would spend the required time with their patient discussing the differences between saving ALL the abdominal muscle (a DIEP flap) and having to sacrifice a very small amount (a muscle-sparing type 2 free TRAM).

The truth is this.... in some (very few) instances, patient's do not have the appropriate anatomy to allow for a DIEP flap. Though this happens rarely in our practice, it does still happen on occasion. Trying to "force" a DIEP flap out of a patient who does not have favorable anatomy requires more muscle dissection and will significantly increase the risk of nerve damage to the abdominal muscle. The potential resulting loss of tone, strength and function will place the patient in a much worse position than if she'd had a muscle-sparing type 2 free TRAM flap to begin with (postage-stamp sized piece of muscle sacrificed).

Please do not be adamant going in to the consult about which procedure you're to receive. As long as you have chosen an experienced microsurgeon specializing in these procedures chances are that you will indeed get a DIEP flap. BUT, your anatomy is the deciding factor. Your surgeon didn't give that to you, he just has to work with it.

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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Christina Applegate Mastectomy Calls Attention To Need For Team Approach To Breast Cancer Reconstruction

Actress Christina Applegate’s public disclosure of her breast cancer, her decision to have a double mastectomy, and plans to go forth with breast reconstruction surgery, calls attention to the need for a medical “team” approach in the treatment and recovery from breast cancer.

“A decision to have breast reconstruction is a decision to have plastic surgery. And, that ought to be done by a plastic surgeon. This is what we train for and do everyday. Plastic surgeons have pioneered and refined all of the state-of-the-art techniques in breast reconstruction including implant approaches and autologous tissue (natural) transfers,” said Richard D’Amico, MD, president of the American Society of Plastic Surgeons (ASPS).

The methods for treating women with breast cancer have evolved and we are seeing scientific advancements in the treatment of this disease. These improvements can be attributed to a strong collaboration between medical specialties, in particular radiologists, pathologists, psychologists, general oncologic surgeons, medical oncologists, and plastic surgeons.

The ASPS says breast cancer patients should insist that their treatment be handled by a “team” of physicians, including plastic surgeons, with the appropriate expertise for each procedure and level of care. This, in turn, gives the breast cancer patient the best chance for positive outcomes.

“ASPS Member Surgeons are carrying out the cutting-edge research for constant outcomes improvement. Our members have the foremost training, education and experience in breast reconstruction, and should be a part of every breast care team,” said Dr. D’Amico.

Patients should not assume that anyone other than a board-certified plastic surgeon affiliated with an accredited facility is qualified to perform breast reconstruction. While technology has made breast cancer diagnosis, treatment, and reconstruction better than ever, it does not negate the need for medical expertise within each area.

According to a recent breast reconstruction study published in the Journal of Plastic and Reconstructive Surgery, 98 percent of elective mastectomy patients would have breast reconstruction again.

“That’s a success and satisfaction rate that should not be compromised,” said Dr. D’Amico.
According to ASPS statistics, more than 57,000 breast reconstruction procedures were performed in 2007.

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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 the DIEP flap procedure. 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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Immediate Breast Reconstruction After Mastectomy is Safe, ASPS Study Says

Breast Reconstruction Does Not Impede Chemotherapy, Recovery or Diagnosis of Breast Cancer Recurrence.

Debunking the myth that women with locally advanced breast cancer must wait until after chemotherapy to have their breast reconstructed, a study presented at the Annual ASPS/PSEF/ASMS Meeting found that immediate free flap breast reconstruction for women with breast cancer is safe and psychologically beneficial.

The study, which followed 170 patients with locally advanced breast cancer, found that immediate reconstruction did not delay post-operative chemotherapy, prolong recovery or hinder the diagnosis of local cancer reccurrence.

"Losing a breast is traumatic," said ASPS Member James Watson, MD, and participating surgeon in the study. "As a board-certified plastic surgeon, I wanted to ensure that immediate breast reconstruction was safe for my patients and would make the healing process easier. The findings in this study will allow women to start healing sooner psychologically, knowing that their decision will not impede their physical progress against breast cancer."

The paper states that women participating in the study were pleased with their immediate reconstruction experience, indicating an immeasurable emotional benefit patients gain by having the reconstruction right away.

According to the findings, the majority of patients were either satisfied or very satisfied with their reconstruction and, if they had to, would have it done immediately after their mastectomy again. Also, the majority of women agreed they would recommend immediate reconstruction to a friend or colleague.

Through the study, Dr. Watson found that immediate free flap reconstruction - where the patient's own tissue is removed from the abdomen, buttocks or thigh regions and reattached in the breast using microsurgical techniques - resulted in similar complications and delays of post-operative chemotherapy to patients who delayed reconstruction. The most common postponement for patients was waiting for the wound to heal. However, the maximum delay was only three weeks, which did not have significant oncological impact on their post-operative therapy.

Also, while there were local recurrences of the cancer, physicians were able to diagnose the cancer's return quickly, resulting in no delay for additional treatment. Most local recurrences were located at the mastectomy scar or in the mastectomy flaps, which could be diagnosed by a physical exam and biopsy.

"An added benefit to reconstructing the breast immediately is that it's easier for the oncology surgeon to complete the mastectomy. Often, the breast cancer is so large or involves so much skin that the surgeon has to remove additional skin in the region, making it difficult to reserve enough tissue to close the wound," stated Dr. Watson. "With immediate reconstruction, the oncologic surgeon can eliminate more breast skin to ensure the cancer is removed and use the skin from the free flap procedure to close the wound."

According to ASPS 2001 statistics, more than 190,000 women were diagnosed with breast cancer and more than 80,000 women opted for breast reconstruction following a mastectomy.

Access to breast reconstruction following a mastectomy has increased due to the passage of the Women's Health and Cancer Rights Act 1998, proudly supported by ASPS, which mandated insurance coverage for breast reconstruction and the alteration of the opposite breast for symmetry for women who have undergone a mastectomy.

"With the finding that reconstruction right after mastectomy is safe, women can maximize their opportunity to not only heal physically but also psychologically right away," said Dr. Watson. "Before, women had to wrestle with their changed body image after losing a breast while physically recovering from their battle with cancer. Now, they don't have to delay the psychological healing process of beating breast cancer and celebrating that victory."

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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 the DIEP flap procedure. 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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Previous Abdominal Surgeries Increase Risk of Abdominal Complications following DIEP Flap Breast Reconstruction

A study published in the May edition of "Plastic and Reconstructive Surgery" has shown that patients who have had previous abdominal surgery are at an increased risk of suffering abdominal complications following DIEP flap breast reconstruction. Here is the abstract:

DIEP Flaps in Women with Abdominal Scars: Are Complication Rates Affected?

Plastic & Reconstructive Surgery. 121(5):1527-1531, May 2008.

Parrett, Brian M. M.D.; Caterson, Stephanie A. M.D.; Tobias, Adam M. M.D.; Lee, Bernard T. M.D.

Background: Previous abdominal surgery may affect perforator anatomy and complication rates in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. The purpose of this study was to determine whether abdominal scars in DIEP breast reconstruction have an effect on flap and donor-site complications.

Methods: Over a 3-year period, 168 DIEP flap patients were retrospectively divided into a control group with no previous abdominal operations and a scar group with previous abdominal procedures. Flap and abdominal wound complications were compared between the two groups.

Results: Ninety patients (54 percent) underwent 114 flaps in the control group and 78 patients (46 percent) underwent 104 flaps in the scar group. The most common previous incisions were Pfannenstiel, laparoscopic, and midline. There was no significant difference between the groups in age, body mass index (mean 27 kg/m2 in both groups), smoking history, or radiation status. There were no significant differences between the control and scar groups in DIEP flap loss (1.8 percent versus 2.9 percent), partial flap loss (1.8 percent versus 1.0 percent), or fat necrosis (15 percent versus 14 percent, respectively). However, the scar group had a significantly higher rate of abdominal donor-site complications (24 percent) compared with the control group (6.7 percent; p = 0.003). The most common complications were abdominal wound breakdown (12 percent), seroma requiring operative drainage (6.4 percent), and abdominal laxity or bulge (5.1 percent).

Conclusions: With minor technical modifications, DIEP flaps can be performed successfully without increased flap complications in patients with preexisting abdominal incisions. Despite these design modifications, patients should be informed of an increased risk for donor-site complications.

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Here's my take...

While we have not seen such a high rate of complications in our practice, I agree with the conclusions of this study completely. There is no question that the DIEP flap procedure is associated with far fewer abdominal complications than the TRAM flap. However, that does not mean that DIEP surgery is free of risk.

The complexity of any surgery and the potential complications increase when operating on parts of the body that have undergone previous surgeries. The abdomen is no different to any other part of the body. Patients undergoing DIEP flap breast reconstruction must be aware that they are facing increased risk in terms of abdominal complications compared to patients that have never had abdominal surgery. This study has underlined this. As a general rule of thumb, the more scars on your belly the higher your risk probably is.

I personally would have liked this study to have included a second group of patients that had undergone TRAM flaps (instead of DIEP flaps) for comparison of complication rates between the 2 groups. If the complication rate is 24% for a DIEP patient, what is it for a TRAM patient that has had multiple previous surgeries? Results of previous studies suggest that it would be even higher in TRAM patients.

It is also important to remember however that just because a patient has had previous abdominal surgery does not mean they are not a DIEP candidate. While the patient must be informed of the increased risks, previous abdominal surgery is not a reason to deprive her of what is very likely still her best reconstructive option.

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 the DIEP flap procedure. 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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Fat-Derived Stem Cell Enhanced Breast Reconstruction for Lumpectomy Repair

Article by Pam Stephan

Cytori Celution Improves Soft Tissue Transplantation
A lumpectomy is less drastic than having a mastectomy, but it leaves you with a scar and a dimple where a smooth, full curve used to be. The breast can also end up much smaller causing significant breast asymmetry in some women. This asymmetry is often exacerbated by the contraction (shrinkage) caused by the radiation therapy that usually follows lumpectomy. An investigational breast reconstruction technique is being studied that uses your own fat and stem cells to repair the shape of your breast. This technique is called Cell-Enhanced Reconstruction, and was presented at the 2007 San Antonio Breast Cancer Symposium.

A Technique for Partial Breast Reconstruction
Women who have had breast-conserving surgery (lumpectomy, partial mastectomy) currently do not have any options for breast reconstruction. Mastectomy patients can choose from implants and tissue flap procedures for recreating a lost breast, but lumpectomy patients have been left behind - until now.

Japanese Investigational Study
Dr. Keizo Sugimachi, of Kyushu Central Hospital in Fukuoka, Japan, has used this new fat graft procedure on 21 patients, 79% of which said they were pleased with the results. His colleague, Dr. Kitamura, who led the Japanese study, said, "The investigational procedure offers hope to partial-mastectomy patients who have limited options," said Dr. Kitamura. "Unfortunately the concept of 'breast conserving therapy' can often times be misleading, as even minimally invasive resections can result in defects that leave patients dissatisfied with the cosmetic outcome."

Stem Cell Enhanced Breast Reconstruction
Cell-enhanced reconstruction uses your own fat tissue (adipose) that is a rich source of stem and regenerative cells. These stem cells are not the controversial embryonic stem cells. Soft tissue transplants have been done for many years, but this new procedure uses a special process to ensure that the transplanted cells will live and adapt to the transplantation site. The process was developed by Cytori, and uses a machine called CelutionTM System EU.

Stem and Fat Cell Liposuction and Injection
Cytori Celution System is used to remove fat and stem cells. These cells are processed to create a mixture of concentrated stem cells combined with fat cells. This concentrated mixture is injected into your lumpectomy area in 3 places, to fill out the missing tissue. Your breast won't immediately look like it has been repaired; it will need about a month for the transplanted cells to settle into position and fill out the lumpectomy cavity.

The Reconstruction Technique:
1: Standard liposuction removes fat, regenerative, and stem cells from abdomen.
2: Cells go into the Cytori Celution processing system
3: Celution system separates regenerative and stem cells from fat cells. The regenerative and stem cells are then washed and concentrated.
4: The concentrated stem cell mixture is combined with the fat cells.
5: The final mixture is injected into the lumpectomy area, where it fills in and replaces tissue volume.

One Surgical Procedure
Fat cells (adipose tissue) can be extracted from your abdomen, thighs, hips, or lower back. Only one surgical procedure is required for this breast reconstruction technique. In the Japanese study, patients were followed for up to 18 months after the procedure, with no loss of tissue volume and no recurrence of breast cancer.

Planned Clinical Studies
Women who participate in a clinical trial of cell-enhanced reconstruction must be recovered from their breast conservation surgery and any follow-up treatments, and must be recurrence-free for at least two years. There will be two clinical trials in Europe during 2008, which will involve about 90 patients. If approved, clinical studies will begin in the United States after 2008.

Sources:
1) Kitamura K, et al "Stem cell augmented reconstruction: a new hope for reconstruction after breast conservation therapy" Breast Cancer Res Treat 2007; 106 (Supp1): Abstract 4071.
2) Medpage Today. Medical News from SABCS: San Antonio Breast Cancer Symposium Meeting. Fat-Derived Stem Cells Used for Breast Reconstruction. Published: December 17, 2007.
3) Cytori Therapeutics. Cytori Therapeutics Receives FDA 510(k) Clearance for the Cytori Fat Transfer System. Published: December 12, 2007.

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Breast Cancer patients may benefit from picking own breast surgeon

Women with breast cancer who are involved in the process of selecting their surgeon are more likely to be treated by more experienced surgeons and in hospitals with established cancer programs, according to a study published in the Journal of Clinical Oncology.

Surgeon and hospital characteristics can influence the outcomes of cancer treatments, the authors explain, but little is known about the factors that influence how referrals are made.

Dr. Steven J. Katz from the University of Michigan, Ann Arbor, and colleagues used survey data from women recently diagnosed with breast cancer and their attending surgeons to determine how surgeons are selected, and if there is any association between the referral process and characteristics of the surgeon and hospital.

Most women were referred to their surgeon by another doctor or by their health plan. They chose their surgeon for a number of reasons -- the surgeon's reputation, the institution's reputation, the recommendation of family or friends, or convenience of the location.

The investigators found that 54.3 percent of women were referred and did not select their surgeon; 21.9 percent were referred, but were also involved in selecting their surgeon; 20.3 percent selected their surgeon and were not referred by a provider or plan; and the rest of the patients had a prior relationship with their surgeon.

Women who selected their surgeon by reputation were twice as likely to have a surgeon who performed many procedures (high-volume surgeon) and to be treated at a cancer center designated by the National Cancer Institute or a program approved by the American College of Surgeons, the team reports.

Patients referred by another doctor or health plan were less likely to be treated by a high-volume surgeon or in hospitals with approved cancer programs, the researchers note.

Previous studies have shown that surgical patients often have better outcomes if they are treated by highly experienced surgeons and at hospitals that perform many similar procedures each year.

More research is needed to investigate the implications of the different referral patterns in this study, Katz and colleagues point out. "In the meantime, women with breast cancer should be aware that provider-based referral might not connect them with the most experienced surgeons or the most comprehensive practice setting in their community."

"Patients might consider a second opinion," the researchers suggest, "especially if they are advised to undergo a particular procedure without a full discussion of treatment options or a clear medical rationale for the recommendation."

SOURCE: Journal of Clinical Oncology; breastcancer.org

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Breast Cancer Gene Testing Less Likely Among Blacks

NEW YORK (Reuters Health) - African American women are generally less likely than white women to pursue genetic testing for BRCA1 or BRCA2, the gene mutations associated with an increased risk of break cancer, researchers report. However, African American women with a recent diagnosis of breast cancer are much more likely to do so, according to the article in the Journal of Clinical Oncology.

"Everybody deserves consideration for testing if their clinical and family history situation warrant it," Dr. James P. Evans, from the University of North Carolina at Chapel Hill, told Reuters Health. "Regardless of race, one has to approach genetic testing as an important option and explain the pros and cons to the patient."

Evans and associates examined race and the timing of breast cancer diagnosis and the frequency of BRCA1/2 genetic testing among women attending the UNC Cancer Genetics Service.

Among 768 women diagnosed with breast cancer who were offered BRCA1/2 testing, the rates of testing among African American and white patients did not differ, authors report.

Overall, African American women were 46 percent less likely than white women to undergo BRCA1/2 genetic testing, the author report.

Women who were diagnosed recently had a higher odds of pursuing testing than did women diagnosed more than 1 year before genetic evaluation, the investigators say, but this difference was statistically significant only for African American women, who were almost three-times as likely to undergo genetic testing.

Why a recent breast cancer diagnosis increases the use of BRCA1/2 genetic testing so "dramatically" among African American "could contribute to a better understanding of racial disparities in genetic testing and medicine," the authors conclude.
"We continue to aggressively try to find avenues for women who need testing but can't afford it, Evans said."One of the most interesting (and distressing) features of our study in my mind is that almost half of the patients who could benefit from testing can't get it...either because they had no insurance or their insurance was inadequate. Only through our special program were we able to provide it for all those patients."

Maximizing the use of BRCA1/2 testing requires "good genetic counseling and a personalized attentive approach on the side of the medical team," Evans advised. "We try to take a lot of time to explain the nuances to women and why testing can be of help to them and their families. I think this is especially important with African American patients where there is traditionally a lower level of trust in the medical profession (understandably)."

SOURCE: Journal of Clinical Oncology, January 1, 2008; breastcancer.org

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Bif Naked Fighting Breast Cancer By Making Music

Bif Naked, Canadian punk rocker, 36-year-old newlywed, vows to keep working on two new albums while in treatment for breast cancer. Bif, born Beth Torbert, found the breast lump herself while doing a regular breast self-exam. Bif is known for her healthy lifestyle, strict vegan diet, dedicated workout routine, and regular yoga sessions.

"I have never been one to give up when an obstacle is placed in front of me. I am in the fight of my life, and I'm lucky to have the support of my husband Ian and many friends and family members," said Bif. She plans to continue work on her sixth album, as well as a new project with Spanish-born, death-metal guitarist La Machina, to be called Jakkarta.

Bif Naked's treatment will include surgery, radiation and chemotherapy.

Source: breastcancer.about.com

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Breast Reconstruction Often Not Discussed

By Megan Rauscher

NEW YORK (Reuters Health) - Women with breast cancer faced with treatment decisions are often not told by their surgeons about the possibility of breast reconstruction after a mastectomy, a study confirms. When these conversations do occur, many more women choose mastectomy, researchers found.

In a survey of 1,178 women who had breast cancer surgery, only 33 percent reported that their surgeon had discussed breast reconstruction with them during the surgical decision-making process.

"We found it surprising that very few patients were informed about their options for breast reconstruction, and that information regarding reconstruction was more likely to be given to younger women who were more educated," Dr. Amy K. Alderman of the University of Michigan Medical Center, Ann Arbor, told Reuters Health.

The survey, posted online Friday by the medical journal Cancer, also indicates that women who had these discussions with their surgeon were four times more likely to have a mastectomy compared to women who did not discuss reconstruction.

"Women need to be fully informed about all of their surgical options for breast cancer: lumpectomy, mastectomy and mastectomy with reconstruction," Alderman said. "All are great options with the same long-term survival."

Breast reconstruction, continued Alderman, "is a personal decision for each woman that is influenced by her body image, sexuality, fear of recurrence, etc. Women should be educated consumers of their healthcare."

She concluded: "We, as physicians, need to make sure that all women, regardless of the patients' education and socioeconomic status, are fully informed of their surgical choices for breast cancer care."

SOURCE: Cancer, February 1, 2008

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Dieting reduces lymphedema after breast cancer

By David Douglas

NEW YORK (Reuters Health) - Weight loss appears to be an effective way to reduce breast cancer-associated lymphedema of the arm, according to UK researchers.

Lymphedema is common, chronic condition that often develops after breast surgery, in which excess fluid collects in the lymph nodes and vessels in the armpit. Treatment for this condition has usually "centered on skin care, external support and compression, exercise and movement and simple lymphatic drainage," lead investigator Dr. Clare Shaw told Reuters Health.
"This is the first time that weight reduction has been shown to influence the size of a lymphedematous arm," the researcher points out.

Shaw of the Royal Marsden National Health Service Foundation Trust, London, and colleagues note that obesity is a risk factor for lymphedema of the arm as well as for poor response to treatment.

To investigate whether weight reduction might benefit in these patients, the researchers studied 21 obese women with breast cancer-related lymphedema. Their average body mass index (BMI) was 32. BMI is the ratio of height to weight used to estimate if individuals are overweight or underweight. People with a BMI of 30 or greater are considered obesity.

The patients were randomly assigned to receive specific dietary advice aimed at cutting out 1,000 kcal per day or to receive an information booklet on healthy eating.

After 12 weeks, the intervention group had lost an average of 3.3 kg (7.3 lbs), their BMI was reduced by an average of 1.3, and excess arm volume fell from 25 percent to 15 percent. There were no changes in weight or in arm volume in the control group.

"Weight management should become an integral part of the management of breast cancer-related lymphedema," concluded Shaw. Overweight patients should be given information on the potential benefits of weight reduction and support to help them achieve it.

SOURCE: Cancer, October 15, 2007.

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Double Mastectomies To Prevent Breast Cancer Increase

From 1998 through 2003, the rate of double mastectomies among women in the United States who had cancer diagnosed in only one breast more than doubled, according to a report in the Journal of Clinical Oncology.

"Many surgeons had noticed that more women were requesting double mastectomy for treatment of the cancer in only one breast. So, we weren't surprised by the overall trend, but we were very surprised by the magnitude," lead author Dr. Todd M. Tuttle said in an interview with Reuters Health.

What is driving this trend will require further studies, added Tuttle, from the University of Minnesota in Minneapolis. In the meantime, he advised, it is critical that physicians be aware and inform their patients that "although there may be sound reasons for undergoing double mastectomy (avoidance of future mammograms and preventing a new cancer), the procedure does not improve breast cancer survival."

The new study involved an analysis of data for 152,755 women who were diagnosed with cancer in one breast between 1998 and 2003 and entered in the Surveillance, Epidemiology, and End Results (SEER), the US National Cancer Institutes' database.
Overall, 4,969 patients elected to undergo preventative mastectomy in the other breast. The rates of the operation were 3.3 percent among women who had any surgery, including those who underwent single mastectomy or only had their tumor removed, and 7.7 percent among mastectomy patients.

The overall rate of double mastectomy - that included removal of an unaffected breast climbed from 1.8 percent in 1998 to 4.5 percent in 2003, the report indicates. Among mastectomy patients, the rate rose from 4.2 percent to 11.0 percent. These trends were noted for patients at any cancer stage and were still apparent at the end of the study period.

Characteristics of the women who underwent double mastectomy included younger patient age, non-Hispanic white race, lobular breast cancer type, and a prior cancer diagnosis, the researchers found. Large tumor size was associated with an increase in the overall rate of the procedure, but with a decrease in the rate among mastectomy patients.

"The main unanswered question from this research is: why are more women choosing to undergo double mastectomy?" Tuttle said. "For our next research project, we will interview breast cancer patients before and after surgery to determine what factors influenced their surgical decisions. We will also interview patients' surgeons to determine their advice."

AUTHOR: Anthony J. Brown, MD
SOURCE: Journal of Clinical Oncology, October 22, 2007 online.

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High Risk of Breast Cancer: 4 Factors

Breast cancer has struck within my family, and when it did I was worried not only for my relative (she's fine now, thank goodness), but also for myself.

After her diagnosis, when I asked my doctor if I should do anything beyond the norm to safeguard my health, the doctor's answer was, "Many more women who have no known relatives with breast cancer get the disease than do those who have a family history."

This was her way of reassuring me, and I've continued to live healthy by getting the usual screenings and not worrying constantly that I will be diagnosed. Every year I schedule my mammogram, and every so often I do a self exam, and I tell other women to do the same. These are the best cancer-fighting aids we have: awareness, action, and advocacy.

To get a quick snapshot of your own risk, based on your family history, Therese M. Bevers, M.D., medical director of the Cancer Prevention Center at The University of Texas M. D. Anderson Cancer Center, suggests you ask yourself the four following questions:

1. Do you have at least two blood relatives who were diagnosed with breast cancer before menopause?

2. Do you have a blood relative who was diagnosed with breast cancer before menopause and a blood relative who developed ovarian cancer at any age?

3. If you have a family history of breast cancer, were any of the diagnosed relatives male?

4. Is your family of Ashkenazi Jewish descent?

If you answered yes to 1, 2 or 3, or to 4 along with any other question, your family history of breast cancer implies a genetic predisposition, says Dr. Bevers.

Talk with your doctor about whether you should consider seeing a genetic counselor, who can give you a much more complete assessment of your risk. (You can also find a genetic counselor yourself at the National Society of Genetic Counselors.

If you learn that you are indeed at high risk, organizations like FORCE, Facing Our Risk of Cancer Empowered, can provide additional information and support.

One more very important point: The American Cancer Society now recommends that certain women who have a higher-than-average risk of breast cancer get a breast MRI along with their mammogram; and depending on the details of your family history, you may need to start screening as early as age 30 or sooner.

The test is able to spot changes that the X-ray might miss (though be warned that means a higher chance of an unnecessary biopsy). Who exactly should consider it? Women who have tested positive for a BRCA mutation; those who have a first-degree relative with a BRCA mutation; women who had radiation to the chest between the ages of 10 and 30 and those whose lifetime risk is 20 percent or higher.

If you said no to all of the questions listed above, or yes only to number 4, you are likely at average ris, which is probably lower than you think. A woman who has no family history has just a one in 13 chance of developing breast cancer in her lifetime, according to large study published in The Lancet.

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Author Bio: Lucy Danziger is the editor-in-chief of SELF magazine. In 1991, SELF founded the Pink Ribbon to raise awareness and funding for breast cancer research. Each October, SELF produces a Breast Cancer Handbook feature. The 2005 handbook won a National Magazine Award for Personal Service. Danziger lives in Manhattan with her husband and two children.

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