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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