Monday, 06 May 2013 00:00
By Dr. Cynthia Paulis
When attorney Barbara Gay found a lump on her breast she went to her doctor for evaluation and was referred to a surgeon to have a biopsy. It took a week before the results came in. “I remember he looked at me and said, “You have breast cancer,” then he spun his stool around and wrote a note in the chart and handed me a piece of paper with an appointment to have it removed.” Barbara didn’t really know what her options were or where to go for help. That was seven years ago. She had two lumpectomies because the first surgery missed some areas of cancer, chemotherapy every three weeks for six sessions and then six weeks of radiation five days a week. She sought out a support group and learned from other women about treatment options and their experiences.
“Everybody is really different as to the risks they’re willing to take, the amount of surgery they are willing to undergo, the amount of time they can take off work, and their insurance coverage. I wanted to work as much as possible during the treatment. I wanted things to be as normal as possible and I also feared losing my job and health insurance. Several women in my support group had the same issues. Many women I’ve known who have breast cancer are limited in their treatment choices by the kind and amount of insurance they have. Insurance companies used to fight covering an overnight stay in the hospital after a mastectomy or breast reconstruction, which is a form of plastic surgery.”
Many women opt for a mastectomy because they live too far from anywhere they can get radiation treatment daily for six weeks which is required when one goes the lumpectomy route.
In 2005 when Barbara was diagnosed, implants were the most common form of reconstruction and the choice was between saline and silicone, both which had significant drawbacks. “Members of my support group discussed the pain involved with the insertion of the spreaders in the chest, which were gradually expanded to accommodate the implants.” Implants also come with risks such as rupture, infection and have to be replaced after roughly ten years, requiring more surgery.
Dale, a woman in her 70’s from Plainview has been dealing with the after affects of implants since she was diagnosed with breast cancer 14 years ago. “In l998 I had a lumpectomy, chemo and radiation and then the cancer came back. In 2010 I had bilateral mastectomies and then had implants put in. My left chest kept collapsing and getting infected. I was on so many rounds of antibiotics. I had green pus pouring out of my chest. The implants were removed. When I went back to the doctor, I was sitting in my hospital gown and he said to me, “You’re a nice lady but I’m sorry there is nothing more I can do for you.” He handed me a piece of paper with the names of other doctors on it. I was shell shocked. The next day he disappeared and no one knows where he is.” Dale has had to go for hyperbaric treatment for the chest infection and now has an opening in her chest that won’t close. “I’ve had three operations in 3 ½ weeks. I am now going to a doctor who specializes in latissimus flap surgeries which my other doctor did not specialize in.”
Women today have many more options available to them than they did when Barbara and Dale were diagnosed. As Barbara commented, “The point is that a breast cancer diagnosis doesn’t automatically entail mastectomy and reconstruction. There are often a series of decisions to be made- lumpectomy vs. mastectomy, reconstruction vs. prosthesis, implants vs. flap.”
Newer procedures that are starting to gain favor are the tissue flap procedures where tissue is removed from the abdomen, back, thighs, or buttocks to rebuild the breast. The two most common types of flap procedures are the TRAM flap or transverse rectus abdominis muscle flap which uses tissue from the lower abdomen and the latissimus dorsi flap, which uses tissue from the upper back. In both of these cases healthy blood vessels are needed for the tissue’s blood supply so flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.
In a TRAM flap the skin, fat, blood vessels and at least one abdominal muscle are removed from the abdomen to the chest wall. There are two types of TRAM flaps a pedicle flap where the flap is attached to the original blood supply and tunnels it under the skin to the breast. The other is a free flap where the flap of skin, fat, blood vessels and muscles for the implant are cut from the original location and then attached using microscopic surgery to connect the vesicles. This procedure is a longer process and not done as often but it can result in a more natural shape to the breast.
The latissimus dorsi flap moves muscle and skin from the upper back and is tunneled under the skin to the front of the chest. The side effects of this are pain, weakness in the back, shoulder and arm after surgery.
A newer form of surgery that has been around for about five years, but not everyone is a candidate for is nipple-sparing procedure. In this procedure the patient’s breast skin, areola and nipple remain. An advantage of this procedure is that the breast remains more cosmetically attractive. The disadvantage is that the nipple and areola lose sensation.
Dr. Deborah Axelrod, associate professor of clinical surgery and the director of clinical breast services programs at NYU Langone Medical center specializes in this type of surgery. “This kind of surgery is really for those women who do not have cancer by the nipple but have it peripherally. Someone who had cancer close to the nipple or imaging that showed areas close to the nipple would not be a good candidate and someone with very large breasts is also not a good candidate.”
The procedure is long and can last up to eight hours depending on the breast reconstruction preformed. Dr. Axelrod describes is as “It’s like an envelope, your are taking the letters out and leaving the envelope, so you are leaving the envelop of skin in tact. The nipple stays on the skin but it is also biopsied to make sure there is no cancer.”
Dr. Axelrod acknowledges that women have changed the way breast cancer has been treated. “Women don’t want to be slashed. There is now a team approach to the conversation between the plastic surgeon and the oncologic surgeon to design something so that every time a woman looks down at her chest she won’t be reminded that either that she had this horrible surgery or that she had breast cancer. Women say that they feel much more whole and not as hollow.” She does caution that there are not many long term studies on this type of procedure.
With any kind of surgery it is important to do your research, ask questions and find a physician who is not only experienced but who you feel comfortable with as Patty Harold, an attorney in Garden City shared with me. Her breast cancer was discovered after she fell off a bike. Patty had a lumpectomy as an outpatient and opted not to have plastic surgery. “My advice would be to make sure you have a surgeon whom you have ultimate confidence in. I loved my surgeon and I was less scared because of her. I also think women should bring someone along who can act as their “ears”. Even though the doctor is speaking to you, somehow it is hard to hear. I had friends and family take turns in visiting doctors with me so they could listen, take notes, and help me make decisions when needed.”
Dr Karen Barbosa, breast surgeon specialist at Winthrop University Hospital brought up some interesting points when asked what is the most important thing a woman can do when given a diagnosis of breast cancer,” Women are being rushed into the OR without looking at what their options are, just because we found it today doesn’t mean it started today. By the time breast cancer is picked up clinically by imaging it has been in the breast approximately three to seven years, so jumping into the OR next week isn’t going to change your prognosis. So really vet your options.” She continued that there is also another option called onco plasty which brings together balanced surgical removal of the cancerous lesion and at the same time paying attention to the incision to optimize the cosmetic outcome.” Dr. Barbosa advises that when women look for a surgeon to handle breast cancer find someone who specializes in that area. “Most people don’t realize that there are surgeons who only do breasts. It makes a difference in terms of being up to date and what are the options and treatments. There are a lot of general surgeons out there and some do breast surgery but make sure they have the ability to understand all the updated options out there. When was the last conference on breast surgery he attended? There are all different levels of education out there so this is something a patient should consider when making a decision.”