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 "Anything we can do to increase awareness of reconstruction and the
relative risks and benefits will empower more women to make an
informed decision," said lead author Dr. Lisa Schneider, a surgeon
at the Institute for Advanced Reconstruction at the Plastic Surgery
Center in Shrewsbury, New Jersey.
Schneider and her coauthor, Dr. Babak J. Mehrara, a plastic surgeon
at Memorial Sloan Kettering Hospital in New York, reviewed previous
studies of breast reconstruction to understand what influences women
to opt out of the procedure.
In the U.S., less than 40 percent of women who have a mastectomy for
cancer treatment undergo immediate breast reconstruction, the
authors point out in the Journal of the American College of
Surgeons.
One myth the authors address is the notion that women don't care
whether they undergo reconstruction. On the contrary, the authors
found, women who choose reconstruction show improvements in mental
health, social functioning and body image, compared to those who
don’t.
Feelings about body image and whether reconstruction represents
having “triumphed” over the cancer, will vary from woman to woman
for cultural and other reasons, the authors note. But, at least one
high-quality study included in the review found that more important
than age, ethnicity or socioeconomic background in predicting
whether a woman would undergo reconstruction was if her surgeon
mentioned the possibility in their first meeting.
Some doctors, too, may be relying on out of date perceptions. The
authors point to a 1998 survey of surgeons specializing in breast
cancer that found more than a third of the doctors believed
reconstruction might delay detection of a cancer recurrence and 17
percent thought it was associated with high complication rates.
Women may also worry about complications, but the review found that
the rates are similar with and without reconstruction.
Fears that immediate reconstruction will delay the start of
chemotherapy can also lead women to avoid the procedure. Several
studies the authors reviewed found that reconstruction didn't
significantly change how long women waited to start chemotherapy
after a mastectomy.
Concerns that reconstruction increases the risk of cancer returning
and delays detection of new tumors also loom large. But multiple
large studies over a 20-year period found no increased rate of
recurrence with reconstruction. Previous research has also found
that reconstruction doesn't delay diagnosis of new malignancies.
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Moreover, there are several advantages to immediate reconstruction,
including limiting the number of surgeries, according to Dr. Anees
Chagpar, director of The Breast Center at Smillow Cancer Hospital at
Yale-New Haven in Connecticut.
"When patients opt for immediate reconstruction, the cosmetic
results tend to be superior, as a skin-sparing procedure is
performed which preserves the skin envelope and the shape for the
plastic surgeons to fill," Chagpar said.
"For some women, there is also the psychological advantage of never
being completely flat, which is important for their body image and
feeling of femininity," she said, adding that those who do seek the
procedure should be able to afford it because the U.S. has long
required insurance to cover reconstruction after breast cancer
surgery.
But access remains a road block for some women, Chagpar said. "In
large academic medical centers, or those with well-trained plastic
surgeons, I think the majority of women who opt for mastectomy get
reconstruction," she said. "However, my sense is that such services
are not available everywhere, and patients who may be treated in
more rural locations may not be offered reconstruction."
Patients who are black, have lower education levels, or significant
medical problems in addition to cancer are less also less likely to
have reconstruction, said Dr. Monica Morrow, chief of the breast
service in the surgery department at Memorial Sloan Kettering Cancer
Center.
Nonetheless, Morrow said, "Some women who choose mastectomy simply
don't want reconstruction" (see Reuters Health article of August 29,
2014 here: http://reut.rs/1qmXYt4). And some women who opt not to
get reconstruction may instead choose breast-conserving surgery, a
smaller operation that leaves them with a feeling in the breast and
a functional nipple.
"As surgeons, it's easy to think that the most powerful thing we do
is with our hands and scalpels, but the conversation we have with
women about their prognosis and their options after surgery is also
very important,” Schneider said.
SOURCE: http://bit.ly/1yHmckj Journal of the American College of
Surgeons, online December 6, 2014.
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