Breast reconstruction: Has the pendulum swung too far the other way?

Once upon a time, women with suspicious breast masses were put under general anesthesia for surgery not knowing whether they were going to wake up with or without their breast. If the biopsy showed cancer, the surgeon went right ahead with the mastectomy. No time to lose.  It’s cancer, you know. Breast reconstruction? Don’t be silly. No one does that. You should feel lucky to be alive!

Can you imagine? Doctors making decisions for patients without consulting them, assuming they know best “what women want.”

Thanks to advances in technology allowing ultrasonically guided outpatient biopsies, and our understanding of the biology of cancer, management of breast lumps is very different today. No more signing a “blank check” surgical consent. Waiting a week (or a month) doesn’t materially affect treatment or outcome. And immediate reconstruction is now the rule, complete with mandated insurance coverage.

Wonderful.

But have they gone too far in the other direction?

I’ve had patients with breast cancer who, for their own reasons, are not interested in breast reconstruction. Some want reconstruction so they can look normal in clothes, but don’t care about a nipple (surgically reconstructed or tattooed.) Surprising numbers of these women tell me with dismay of confronting the disapproval of their other doctors.

You don’t want reconstruction? Don’t be silly. It’s covered by insurance. Everyone does it. What’s wrong with you?

Can you imagine? Doctors assuming they know best what their patients want, without listening when women actually tell them things they don’t expect to hear.

And it’s not just surgeons. I got a letter from an oncologist seeing a patient three years after completing treatment that included this: “She did not pursue getting fitted for a mastectomy bra and prosthesis when I gave her a prescription three years ago.”

Yeah, so? I thought as I read, assuming he was just being informative.

Further down, though, the peeved tone comes through more strongly: “I strongly recommended that she be fitted for a mastectomy bra and prosthesis, and gave her written information regarding insurance reimbursement, local fitting stores, and another prescription. She does not appear interested in plastic surgery evaluation.”

Honestly, dude. Back off.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • christieD

    I’m a physical therapist who specializes in the treatment of those with beast cancer. I completely agree with your position. Too many women are being bullied into reconstruction… One even saying to me “you mean I don’t have to do it?” Sad. Women who do express their desire to decline reconstruction are often told “oh, you’ll feel differently a year from now. Just do it.” The problem is, those same people are not in the treatment room with me when the patient is in tears, painful, exhausted from not just treatment of cancer, but also the pain of tissue expansion…and heaven forbid if infection occurs and the expander or prosthesis had to be removed. Too many times I have heard “I wish I never did it.”

  • ButDoctorIHatePink

    I did a right sided mastectomy with “immediate” reconstruction with tissue expanders. Since then, my cancer has metastasized. Knowing what I know now, I would not have done the recon. I have had many functional problems since the surgery to place the implants – shoulder problems, back pain. My exchange surgery was nearly a year past mastectomy, so it was definitely from the 2nd surgery and not the expander placement. My “breast” doesn’t look normal and I’m hardly alone.

    I don’t think doctors really educate us as to what we can expect with recon. We believe we will get a normal looking breast back or at least, Hollywood boobs, but it’s not the case. Reconstructing something that isn’t there is not the same as enhancing something that is, and yet I am not sure women have a good grasp on that. Aside from esthetics, nobody told me that my skin would be forever numb, that I would have a maddening itch I can’t scratch even 4 years later, the shoulder/back pain that would never end, the inability to raise my arms all the way up, and that the implant rubbing on my chest wall with no protective breast tissue would be uncomfortable and still feel false years later. I’d take it out except being metastatic, I don’t want to do an extra surgery.

    Plastic surgeons need to really explain to women what will happen and give us a good overview of both of our options and certainly, any feelings about women’s breasts need to be left at the door.

    I think many are so traumatized at the idea of the amputation we don’t fully understand what’s to come. I saw three doctors and none mentioned any of the things that I’ve experienced, yet I know they are not even remotely uncommon. Only one showed me pictures of what a recon would look like, which was so unlike what you get when you search for “breast reconstruction” online that it was shocking. Perhaps if I hadn’t done the “immediate” recon I wouldn’t have done it at all.

    Many women are happy with their recons, but just as many are happy without them. It does not mean we are more or less a woman and one of the most beautiful women I know had a one-sided mastectomy and just goes as-is. She’s confident and lovely.

    This is truly a choice a woman has to make on her own, but one that she needs help understanding. Certainly, explaining the downside of this surgery is not something that seems to be discussed very often.