Quick Breast Reconstruction Info

For a quick informative of breast reconstruction info/options - visit either our website or The Center for Reconstructive & Plastic Surgery:

http://aaaplasticsurgery.com/

http://www.jcl.com/content/plasticsurgery/default.htm

"After Cancer, Removing a Healthy Breast"

I read a recent article in the New York Times which I found very interesting, and wanted to share with everybody. In the above article from 3/8/10 by Tara Parker-Pope, she discusses the growing number of women opting for mastectomy on the opposite (presumably unaffected) breast, when cancer is diagnosed in one breast.

The number of women choosing this option has nearly doubled in the past few years alone. Overall in 2006, ~6% of women choose to have this done along with the affected breast, and continuing to grow. Among younger women (less than 40 years of age), statistics show that 1:10 women choose this option in a recent study out of the University of Minnesota. This option is chosen even moreso in women who have the in situ type, as shown in a recent publication in the Journal of Clinical Oncology. It rose dramatically from 2.1% of women in 1998 to 5.2% of women in 2005 alone.

Clearly, women with a genetic risk for breast CA lower her chance of ultimately developing a cancer with this preventative measure. However, studies have shown that performing a mastectomy on an "unaffected" breast does not improve the odds of survival. Several studies have reported this recently. There was a small survival benefit in a certain subgroup of women: less than 50 years of age, early-stage, estrogen-receptor (-) tumors without response to Tamoxifen.

The highest risk to women is not from a future cancer, but from the potential spread of that cancer that is already present. So, removing the opposite breast would not have any effect on changing these odds. Women are certainly opting for the above procedure not because of the statistics, but, for the psychological benefit of not wanting to re-experience the trauma of mammogram/biopsy/diagnosis/etc. The fear has been averted (theoretically) by bilateral mastectomy. This is a reasonable option for every woman, and one which should be discussed with the woman so that she can make an informed decision. Most importantly, it is the individual woman's choice.

Risk Reduction of Breast Cancer with Aspirin

A recent publication in the Journal of the American Medical Association (JAMA) noted a reduction in the risk of breast cancer in those women who used aspirin - Volume 291(20);2433-89:2010. While not the first to suggest that aspirin can help prevent breast cancer, notably, it is the first to show a significant difference that aspiring protects against certain hormonally-sensitive tumors (hormone-receptor positive breast cancers).

The investigators suspect that aspirin decreases the production of aromatase, which suppresses the production of estrogen, a hormone noted to fuel the growth of breast cancers. Many of the drugs today target decreasing the production of estrogen, and consequently inhibit aromatase. This study looked at about 3000 women on Long Island, NY, half of which with breast CA. They inquired about their use of aspirin, ibuprofen, and acetaminophen as well as risk factors such as hormone use, menopausal status, reproductive history, and family history of breast cancer.

Results showed those that used aspirin had nearly a 30% reduction in their breast cancer risk. Notably, aspiring specifically affected their risk for estrogen and progesterone positive tumors. These cancers have a better prognosis since they respond to hormonal treatments postoperatively. Ibuprofen had a minimal risk reduction and there was no appreciable reduction seen with acetaminophen. The true effect may not be noticed, since there were fewer people who took these latter drugs.

Although early to say definitively, these results show promising results.

Post-Mastectomy Radiation Therapy...and Breast Reconstruction

Radiation therapy (RT) is a proven and well-accepted modality in treatment (or adjunct treatment) for breast cancer. It is almost always used following lumpectomy, as it significantly reduces the local recurrence rate.

Even following mastectomy, although a definitive procedure for the cancer, may be recommended RT following the mastectomy due to various pathologic findings. Classic indications are:

Certain (aggressive) types of tumors

Tumors 5cm or greater

4 or more positive lymph nodes

Positive (inadequate) margins on specimen

Others, and newer indications, are:

for tumors less than 5cm and 1-3 nodes (+) - include any 3 of the 4: 1-3 nodes (+), LVI, ER (-) tumors, or premenopusal or less than 40 years of age

for tumors less than 5cm and node (-) - include any 3 of the 4: margin less than 2mm, less than 40 years of age

Although a beneficial adjunct for breast cancer in several circumstances, it has also detriments to both the patient as well as plastic surgeon. Above all, treatment for cancer comes before the aesthetics of breast reconstruction, and the proven benefit outweighs the ill-effects of RT. The impact that RT has on the skin, as evidenced by the radiation dermatitis/radiation burn, angiofibrosis, contrcture/fibrosis of the skin, and soft tissue, as well as the healing/infection issues are not favorable.

From the plastic surgery standpoint, these effects are troublesome, especially when dealing with reconstruction. This should be discussed with your plastic surgeon, as it impacts the type of reconstruction you should have. Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation will be needed postoperatively. However, what is not conveyed, is that the above changes may occur and account for some of the breast asymmetry or contractures. Although a "breast conserving" therapy is performed, many women end up seeking a plastic surgeon to assist with these issues, which often times, include the same procedures as if a mastectomy was performed anyhow.

Implant-based reconstruction is not a recommended reconstructive procedure, as already noted in previous posts. The complication rates are markedly increased with often times, poor aesthetic results, let a lone the wound healing, infection, contracture/asymmetry rates, among others. This type of reconstruction usually fairs poorly following RT. There are several studies showing good results following implant-based reconstruction, however. Many times, RT is not known until final pathology returns several days later. If by chance a tissue expander reconstruction was chosen, and RT is later found to be needed for an indication above, I would opt to keep them in, quickly inflate to maximal expansion, then deflate for the RT. Immediately afterwards, quick expansion would be done (e.g., M.D. Anderson protocol). However, exchange for a flap-based reconstruction is always an option if any complications come about during this process.

Radiation after flap-based procedures are significantly better following RT. After a flap procedure (e.g., latissismus, TRAM, or DIEP flap, recruiting well-vascularized tissue from a remote area negates some of the ill-effects that RT has done. There still is a chance for the reconstructed breast to shrink or contract if followed by radiation, but it resists the effects much better than implants. Usually, performing this in a delayed fashion would allow your plastic surgeon to excise all of the affected tissue, and use the flap to reconstruct the defect. This is my preference after, or for known RT. The flap-based reconstructions (e.g., latissimus, TRAM, or notably the DIEP), are excellent options as discussed in previous posts. You may consider delaying your reconstruction for a later date if you know you will be receiving RT postoperatively.

Silicone Implants

Several queries regarding silicone implants have been asked recently in regards to breast reconstruction. Basically, silicone implants have always been able to be used for reconstructive purposes. They were taken off the market for a time period for aesthetic reasons, but re-approved in the last few years for this purpose.

The FDA approved Allergan Corp. and Mentor Corp.'s silicone breast implants and have since returned these devices to the U.S. market. 14 years after the FDA restricted access to the silicone implants, they have been placed back on the market after extensive studies for safety concerns. They were off the market for this reason from 1992 until November 2006.

The approval letter stipulated a number of conditions that the manufacturers needed to satisfy in order to receive FDA final approval to market and sell silicone breast implants in the United States. These letters came after an FDA advisory panel hearing in April 2005, in which the panel heard more than 20 hours of data presentations from the manufacturers and public comment.

Breast augmentation is now the most common aesthetic surgical procedure, according to ASAPS and ASPS statistics. About 380,000 and 58,000 women had breast augmentation and reconstruction, respectively, last year, according to ASPS. Both breast augmentation and reconstruction have been proven in numerous studies to have psychological and physical benefits for women who choose these procedures.

Silicone implants have been proven safe for reconstructive and augmentation purposes and the research behind these implants are excellent. Overall, excellent results are obtained from such implants with the health concerns already addressed and complications of such should be discussed with your plastic surgeon.

Implant-Based Breast Reconstruction and Recurrent Cancer

Many women are fearful, for obvious reasons, that implants may contribute to cancer recurrence or may hinder detection of any recurrent cancer. Implant-based reconstruction is the most common type of breast reconstruction, even today. Recurrence of cancer is always a concern, and thus, studies were performed to evaluate if implants hindered or lengthened the time of diagnosis of recurrence.

The most notable study reviewed two groups of more than 300 women each - women with immediate breast reconstruction with implants and women without any reconstruction. These took into account patient age and stage of the disease. The recurrence rate of reconstructed patients = 6.8% and without reconstruction = 8.1%. There was no statistical difference in detection or recurrence between these groups. Nearly all (~95%) of all recurrences were detected by physical examination alone, with the rest being found via CT scan. Treatment was not affected by the implants. And, generally, did not require removal of the implant. Only 3 of the 21 women who had recurrence had her implant removed, with 2 of 3 requesting to have it removed.

Breast cancer continues to grow in number along with the reconstructive options available. With the growing knowledge of the reconstructive option, more and more women continue to opt for breast reconstruction. Only a few years ago, breast reconstruction was only conducted in approximately 10% of all women with breast cancer. This number has increased over the past few years alone, mostly due to the fact that women are more informed of this option. Overall, immediate breast reconstruction is still a safe procedure with numerous advantages...and as this study shows, has no impact on the identification of a recurrence or any association towards causing a cancer recurrence.

Recent Mammography Recommendations

Recently, the United States Preventive Services Task Force (USPSTF) has recently released recommendations for screening mammography for women. Their recommendations state that such mammograms should be every other year beginning at age 50yo, instead of the current guidelines of beginning at age 40yo (35yo for high-risk women). Mammography has unquestionably saved many lives, especially in women younger than 50yo. At least 10-20% of all breast cancers are diagnosed in these younger women. Breast cancer in younger women is always a more aggressive tumor, and overall, usually a more deadly tumor, especially when not caught early. When detected early and in its earliest and most treatable stage, the recurrence and survival rate is MUCH lower. Women over 74yo are not given specific guidelines for mammography, as they state that their risk of dying from other medical conditions is far greater than that of breast cancer, despite the fact that breast cancer (1 in every 8 women will develop) clearly increases with age.

The current recommendations by the USPSTF are based on old research from 1992-2001. The medical technology, especially in diagnostics, imaging (including digital mammography and breast MRI, breast cancer research (billions of dollars over the past few years alone, and treatment modalities have made huge advances, which accounts for the massive decrease in mortality rate over these past 8 years from the USPTF quoted studies. Regular mammographic screening began in 1990 - the mortality rate of breast cancer, previously unchanged over the past half century prior, has significantly decreased by mre than 30% since its inception. Clinical breast exams are not recommended prior to mammography, as they state that a clinical exam adds no additional benefit from that given by a mammogram. Lastly, this task force has not made any specific recommendation for monthly self-breast exams. As known, many breast tumors are found by women during self breast exams, prompting earlier medical evaluation, or by an experienced physician who may catch many masses not found by the woman.

The USPSTF has blatantly refused to data and research (and arguably, common sense), when these recommendations were made. No physician of the specialties that should have been involved (breast surgery, radiology, or oncology), had any input on theses recommendations. In fact, the American College of Radiology (ACR) and other Boards still stick to the current guidelines of beginning yearly screening mammograms beginning at age 40yo. Their claims of the "hazzards" of mammograms are unwarranted: discomfort, anxiety from false positives and need for possible surgery/treatment, and radiation exposure. Undoubtedly, a life saved from early detection far outweighs any of these concerns. Discomfort and anxiety is overshadowed by catching a breast cancer in its earliest stage. The radiation exposure from a mammogram is minimal. In fact, the radiation given off from the earth itself is much greater. The money saved by not performing mammograms between ages 40-49 will most likely be the opposite effect - with the more aggressive treatments, surgery, and battling of late-stage breast cancer will cost much more in money, time, and lives lost. This potential money savings in health care does not make sense as evidenced by current research and data/statistics in breast cancer research. My fear is that women that can afford to pay out-of-pocket for mammograms at an earlier age will get them and those who don't have these means will ultimately suffer. Saving women's lives and detecting/treating breast cancer at its earliest stages should be of utmost importance. The ACR still supports monthly self-breast exams, yearly physician breast exams, and annual screening mammograms beginning at age 40yo (age 35yo in high-risk women) - these are the best modalities that we have today.