Misconceptions may be keeping many women from getting breast reconstruction after a mastectomy, even though the procedure can help improve quality of life for cancer survivors, according to a new review.
"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Some doctors, too, may be relying on out of date perceptions.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.
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: 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.