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New Options for Breast Reconstruction
Experts Say Many Breast Cancer Survivors Are Uninformed About the Choices
Sept. 17, 2008 -- About 78,000 U.S. women undergo a mastectomy each year, but just 57,100 had breast reconstruction in 2007, according to experts speaking at a web seminar hosted by the American Society of Plastic Surgeons.
For a minority of women, reconstruction of the breast after a cancer diagnosis is simply not important, says Roberta Gartside, MD, a Virginia plastic surgeon and breast cancer survivor who spoke.
But other women, says Gartside, are not fully informed of their options, face financial barriers, or both.
These obstacles exist, Gartside and other speakers say, even though insurance coverage for post-mastectomy breast reconstruction is mandated by the 1998 Women's Health and Cancer Rights Act.
At the seminar, speakers talked about new or improved reconstruction options and what is being done to reduce barriers to the procedure.
Breast Reconstruction Options
By far, the most popular breast reconstruction option is the implant and tissue expander, says Gartside. Other options include using tissue flaps or an implant alone.
In the flap technique, the surgeon repositions a woman's own muscle, fat, and skin, creating or covering the breast mound.
A tissue expander stretches the skin to provide the coverage for the breast implant. Final steps can include recreating the nipple and areola.
Silicone implants are back "and better than ever before," says Andrea Pusic, MD, a plastic surgeon at Memorial Sloan-Kettering Cancer Center in New York.
Once banned, the silicone implants were approved by the FDA for breast reconstruction in women of all ages and for breast augmentation in those 22 and older in 2006.
A study released earlier this year at the annual meeting of the American Society of Plastic Surgeons showed that women who got silicone implants were more satisfied than those who got saline, Pusic says. Women who received silicone implants say they are softer and have less rippling, she says.
Newer generation silicone implants -- the so-called "gummy bear'' implants -- may prove even better, according to Pusic.
Fat injections are being used to fill in deformities left by lumpectomies and mastectomies, she says.
And other research has studied the use of stem cells derived from fat to correct deformities after breast-sparing surgery.
Transplanting donor tissue from a patient's identical twin to reconstruct the breast with a flap technique is another new option, and three such cases are reported in the October issue of Plastic and Reconstructive Surgery.
None of the patients could supply her own tissue for the transplant, for various reasons. One, for instance, was too lean and had no excess abdominal or buttocks tissue to transfer, according to Robert J. Allen, Jr., MD, a surgeon in Charleston, S.C., the lead author of the report. He reports that all three transplants were successful and believes the report is the first documentation of flap transplants for breast reconstruction.
In the future, he writes, such transplants for breast reconstruction might be possible between nonidentical twins.
Breast Reconstruction and Quality of Life
Research is under way to evaluate the personal impact of having breast reconstruction.
A new questionnaire, developed by Pusic, aims to quantify how breast reconstruction affects the patient's quality of life.
Called the Memorial Sloan-Kettering Cancer Center Breast-Q, it measures satisfaction and quality of life by examining body image as well as psychological, social, sexual, and physical functioning.
It is hoped that the results will educate patients and doctors about the value of breast reconstruction for some women, she says.
Breast Reconstruction: The Access Problem
Despite legislation mandating coverage and new techniques for reconstruction, racial and regional gaps exist, says Amy Alderman, MD, assistant professor of surgery at the University of Michigan Medical Center, Ann Arbor.
African-American women are half as likely to have breast reconstruction as whites, for instance, she says.
In one study, 35% of women in Atlanta opted for immediate reconstruction but just 8% of those in Connecticut did.
To find out why more women weren't opting for reconstruction, Alderman searched patient data bases in Los Angeles and Detroit that included more than 2,000 women and found that providers did a "poor job in informing women about their options."
One barrier, she says, is that many of the women didn't have access to a plastic surgeon before their mastectomy. The Society advocates a team approach, with the general surgeon working with the plastic surgeon.
If a woman isn't offered a team approach, the speakers say, she can first find a plastic surgeon and ask him or her to help assemble a team.
A Patient's View
For Michelle Fish, first diagnosed with breast cancer at the age of 39 in 1991, "living with just one breast was not an option." She had a mastectomy and immediate reconstruction.
When she was diagnosed with cancer in the opposite breast in 2005, she had another mastectomy followed by reconstruction.
"Breast cancer is enough to deal with," she says. She wanted to be spared the embarrassment of looking "lopsided" or having a prosthesis slip.
While insurance coverage is mandated, she says, she still had out-of-pocket costs. "In 1991, my out-of-pocket costs were $205. In 2005, they were more than $5,000."
Fish says she was with the same employer and on the same health plan for both surgeries. "There was nothing substantially different between the surgeries. That is just how [much] health care has escalated and how much less [insurers] are paying."