If you’ve just been diagnosed with breast cancer, or are choosing to have prophylactic mastectomies for a confirmed BRCA mutation, this information will help you understand your oncological and reconstructive surgery. It is not easy to make decisions in the face of breast cancer. While it is normal to feel a sense of urgency to want the cancer removed immediately, it is important to make educated decisions that are not rushed. It is unlikely that taking a few weeks from the biopsy to the surgery will put you in further jeopardy. You should establish your personal “breast team” including a breast (oncological) surgeon, plastic surgeon, medical oncologist, and possibly a radiation oncologist. It is important to remember that the treatment of breast cancer should be optimized and that any reconstructive surgery should not compromise the oncological result. If you are into algorithms, you could download my usual (every patient’s care is individualized) Breast Cancer Reconstruction Algorithm.
The first decision that you will be faced with is whether to have a lumpectomy or a mastectomy. This is called the “oncological operation”. In some circumstances a mastectomy is the only viable option. Mastectomy remains the gold standard for the surgical management of breast cancer. Patient preferences, radiation requirements, (relative) size of the breast and the tumour as well as the risks of a second cancer in the opposite breast will be taken into consideration by the breast surgeon before making this recommendation. As this operation is a treatment for cancer there may be less choices available to patients. Other procedures which may considered are sentinel lymph node biopsy or more extensive axillary clearance surgery.
Once the oncological procedure has been decided on, the next step is to decide on a reconstructive procedure. Not having a breast reconstruction is an option that some women choose and remain satisfied with this option in the long term. Most women, if given the choice, will opt for some form of reconstruction.
The first decision in reconstruction will be with regard to the timing of the reconstruction. It can be immediate, in which case the reconstruction begins (but may not be completed) at the time of the oncological procedure. It may be delayed, in which case it is performed at a separate procedure some months after the oncological operation, with 12 months being the most common waiting time, although there is no upper limit on the time. Reconstruction is not undertaken during chemotherapy or for some time thereafter. An interesting timing option is that of immediate-delayed, where the reconstructive procedure is undertaken at a separate procedure within 3 weeks of the oncological procedure. This is very uncommonly performed and usually occurs when unexpected oncological findings are encountered and a planned immediate reconstruction is abandoned.
Once you have settled on a timing for your reconstruction, the next question is to decide on the material to be used. Alloplastic reconstruction uses foreign material (silicone) for the reconstruction while autogenous reconstruction uses tissues from your own body for the reconstruction. In certain circumstances these may even be combined to offer the best result.
The final “big decision” is what to do about the opposite breast. In the case of a lobular cancer, it is generally recommended to consider a bilateral mastectomy as this tumour type has a high incidence of bilateral disease. Ductal cancer (which is more common has a much lower, but not zero rate of occurring in the opposite breast. Interestingly, the rates of elective bilateral mastectomy are rising and present about a third of women are considering this option, even it is not medically essential. Even if only one breast is operated on for the cancer, there still remains the question of what to do about the opposite breast in terms of aesthetics and matching. The “matching procedure” may be done at the same time or it may delay for another time. Some patients will not want any surgery on their unaffected breast.
Putting all of this information together in the framework of the oncological requirements and illuminated by your reconstructive goals will help determine the appropriate course of action for you. It is good to remember that the raizon d’etra of breast reconstruction is for the emotional well-being of the patient. There are no “right” or “wrong” options and the choices that you make should be your own. The role of the surgical team should be to guide you to understand the most suitable options but the final reconstructive decision should rest with the patient. It is also important to realize that not every option will be available to each patient and in some cases there may very limited options.