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Sunday, June 12, 2011

Mastectomy? Know Your Options

A woman came to me for help last week; a small breasted woman with early stage breast cancer. She wanted to discuss her options with me. Her preference would be to have a mastectomy, but she was afraid of the cosmetic outcome. She was embarrassed to admit this concern as her doctor had commented that her cancer should be her first priority. I assured her that cancer treatment with a good cosmetic result is possible. I asked her if a nipple-sparing mastectomy (NSM) with the incision through an inframammary fold (IMF) was offered. She just stared at me.

I explained that in some circumstances NSM was possible and that although there are no long-term studies, the five year studies show no increased risk for NSM over skin-sparing mastectomies. It was possible that she would not have to endure additional surgery to reconstruct her nipples and that the outcome would be more natural looking. I also explained that with an IMF (under the bra-line) incision, the scar can be hidden in a natural crease. The relief on her face was amazing.

Why, I ask myself, do more doctors not offer these procedures. Are these procedures more time consuming, more difficult or are some doctors simply not current on new developments in breast cancer treatments and surgical options? Have they lost sight that there is life after cancer? After all, isn’t life-after cancer the main reason for treating cancer? Perhaps the surgery takes longer or is more difficult? I consulted an expert on NSM, IMF MX, Dr Alex Swistel, of the Weill Cornell Breast Center, and his response was that this approach is more difficult and it requires specialized training as it requires instruments that can reach as far as that in a conventional mastectomy. Many experts that have tried it abandoned it for that reason; however, this procedure is best for keeping blood supply to the nipple without cutting around it and really hides the scar very well. This procedure certainly is not for everyone, but reports are now showing virtually no recurrence in the nipple even after 10 years. (Studies done in Italy seem to have the longest follow-up.)

I recently attended a conference on new developments in the treatment of breast cancer: “2011 Meet the Experts: Breast Cancer Education.” I had the opportunity to hear what is new, and also to ask questions of the panelists. Dr Eleni Tousimis, of the Weill Cornell Breast Center (see new link added below for updated information), spoke at length on the latest technological advances in the treatment of breast disease and on minimally invasive techniques, including the latest on NSM. Dr Joshua Levine, of the New York Eye and Ear Infirmary, spoke about the benefits of using one’s own tissue for reconstruction (autologous breast augmentation). Microsurgery has come a long way since its invention by vascular surgeons in the 1960s. The term refers to any surgery involving a surgical microscope. And it has found one of its best applications in breast reconstruction. Through microsurgery, surgeons are able to harvest healthy tissue from one part of a woman’s body and reattach it to the breast area. Through the careful process of attaching blood vessels, microsurgery allows patients to have natural looking breasts made from their own, living tissue. Another benefit is the minimized impact and injury to muscles, allowing patients to enjoy a faster, fuller recovery than with earlier flap reconstruction. For more information, please view the following link.

Many women choose implants over flap reconstruction methods. While breast reconstruction with implants may not always yield as realistic-looking results as tissue-based reconstruction methods, the procedure is less risky and requires less surgery. Generally, implant-based reconstruction results in less scarring and poses fewer risks to the patient than tissue-based reconstruction, making it an attractive option for women who prefer less invasive procedures. I am grateful for my wonderful team, Drs Alex Swistel and Mia Talmor. I chose silicone implants, have my very own nipples and I must say I don’t look as if I have had a mastectomy.

Exciting times in the world of breast cancer surgery. However, one thing I heard at the aforementioned conference was quite disturbing: 30% of all women treated for breast cancer do not choose reconstruction. It is one thing to choose not to have reconstruction; it is quite another to decline it because no one has either offered it or explained that insurance companies are required to cover the costs. Are doctors not discussing this with their patients? Are patients not aware this is an option? Clearly not all options are for everyone, but an informed patient is an empowered one.

I had the opportunity to discuss NSM and other reconstruction issues with Dr Paul Baron, co-founder of the Charleston Breast Center and expert on NSM. He was incredibly informative and I asked him if I could borrow both his knowledge as well as a blog he wrote for The Reconstruction Network: “Who Can Have a Skin-Sparing and Nipple-Sparing Mastectomy and Why”. I have attached the link below as I think you will find it most informative.

While we are still waiting for the cure, much progress has been made in surgical and reconstructive procedures for breast cancer. Oncoplastic surgical techniques can be used to remove the cancer while achieving excellent cosmetic outcomes. NSM and IMF are not an option for all women, and certainly women will have preferences on reconstruction options. However, women need to know that they have options. Information is power and it has never been more important to be informed and knowledgeable about your medical care. My goal is to get this information to women and to empower them to make choices that fit their own individual needs.

For more information on NSM and reconstructive options, please visit: (this link added 10/29/11)

To locate doctors who perform NAM, IMF, and DIEP reconstruction, email me and I will assist you.

Elyn Jacobs

Elyn Jacobs is President of Elyn Jacobs Consulting, Inc. and a breast cancer survivor. She empowers women diagnosed with cancer to navigate the process of treatment and care, and she educates about how to prevent recurrence and new cancers. She is passionate about helping others get past their cancer and into a cancer-free life.

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