Get rid of the cancer first before considering breast reconstruction

When it comes to surgery for cancer, having a “positive margin” is a bad thing.  It means that when the surgeon said he “got it all,” even though he meant it with all of his heart, likely he didn’t.  For a woman undergoing a lumpectomy for breast cancer, that positive margin means a re-excision of the lumpectomy site or alternatively, a mastectomy.  For a woman who has just had a mastectomy, it means that she will likely be seeing me.

I saw a new breast cancer patient on Thursday, a very attractive woman in her early fifties.  She had undergone a mastectomy last March, and had a tissue expander placed at the time to facilitate a later reconstruction with a silicone implant.  The final pathology showed positive lymph nodes on her sentinel node biopsy, and a positive margin where the tumor was close to the chest wall.  She required chemotherapy because of her lymph node involvement, and radiation to her chest wall for the tumor cells that may have been left behind.  She finished her chemotherapy without any difficulty in June.  But instead of coming to me at that time, she elected to complete her reconstruction first.

The first time her expander was replaced with a permanent implant, in August, there were complications which resulted in a failed reconstruction. The plastic surgeon elected to take her back to surgery in November, and replace the implant, and transfer fat cells from her inner thighs to make the reconstructed breast rounder and more perfect.  When the patient saw me on Thursday, she was still not entirely happy with the result, and was looking forward to having additional fat transplanted in the upper inner quadrant.  She guided my hand to the area and said, “See?  The tissue is so thin right there.”  I stared at her reconstruction in amazement.  It was one of the best I had ever seen.

But yes, there was a problem.  It was not a problem that she had concerned herself with.  The problem was that it was nine months after her mastectomy, and that no one had pointed out to her that a local recurrence of her breast cancer, for which she was certainly at high risk, is a harbinger of metastatic disease and death.  In other words, she had failed to grasp the fact that it was her cancer, and not her breast reconstruction, that she needed to pay attention to.  It took me the better part of an hour and a half to convince her that she should proceed with radiation before her plastic surgeon achieved the perfection that she sought, and before her cancer recurred, if it has not already.

I understand the importance of breast reconstruction, and of feeling whole, and feminine again.  But I also understand the evil nature of “the beast.”  I may be a curmudgeon, but I want my ladies to comprehend that it’s not about the boob and the plastic surgeon isn’t going to tell you that — that’s my job.

First and foremost, pure and simple, it’s about getting rid of the cancer. That’s the only priority.  It’s just the way I see it.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries.

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  • Lisa

    I think plastic surgeons push immediate reconstruction without fully informing patients about the drawbacks of reconstruction surgery, both physical and cosmetic. Reconstruction surgery is offered to breast cancer patients as a consolation prize – along the lines of ‘at least you’ll have perky breasts’ or the suggestion you will get a tummy tuck with a DIEP flap.

    I suspect attempts by plastic surgeons to educate the public about reconstruction are really attempts to increase their income: Witness BRA Day (National Breast Reconstruction Awareness Day). One of the slogans on their web site (http://www.bradayusa.org/) is “Know your breast reconstruction options. Make sure a plastic surgeon is on your treatment team.” But my experience, and the experience of many women I have talked to, is that plastic surgeons normally don’t discuss all options, including not having reconstruction or having delayed reconstruction. So I am not surprised that ‘immediate reconstuction’ gets in the way of needed radiation therapy.

    • DoubtfulGuest

      I don’t know much about this, Lisa, but I knew a woman who had a similar experience of being pushed into reconstruction. They said “Look in your closet, think about what you can and can’t wear after surgery…” She stopped them short and replied, “I’ll wear whatever I want to with one side flat.” :)

      • SarahJ89

        Yay for that woman!

      • Lisa

        I’ve talked with women who were required to see a psychiatrist before they were ‘allowed’ to opt out of reconstruction. The pressure can be very intense. Sigh….

        • DoubtfulGuest

          Seriously?! The descriptor that springs to mind for that requirement is “Batsh_t”.

          • Lisa

            Seriously.

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