A “nascent movement to ‘go flat’” is how an article in The New York Times characterized the decisions by some women to opt out of reconstruction following surgery for breast cancer.¹ The article examined the reasons several patients made that decision, which included avoiding multiple surgeries and potential complications as well as resenting and resisting implications that reconstruction would restore their femininity and make them “feel whole again.”

I cannot stress enough that there is no ‘one size fits all’ treatment when it comes to a woman with breast cancer.

— Deanna J. Attai, MD, FACS

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One of the physicians cited in the article, breast surgeon Deanna J. Attai, MD, FACS, noted that more of her patients, particularly women with smaller breasts, are choosing not to have reconstruction. Dr. Attai clarified that statement in an interview with The ASCO Post.

“It’s a growing number,” she said, “but it is still a very small number of my patients.” Dr. Attai is Assistant Clinical Professor of Surgery at the David Geffen School of Medicine at the University of California, Los Angeles, and Immediate Past President of the American Society of Breast Surgeons.

‘No One Size Fits All”

In her online statement on the treatment of breast cancer,² Dr. Attai wrote, “I cannot stress enough that there is no ‘one size fits all’ treatment when it comes to a woman with breast cancer.” For patients scheduled for mastectomy, Dr. Attai said, “I generally recommend that my patients at least be evaluated by a plastic surgeon to discuss what is right for them,” and usually by at least two different plastic surgeons to get a full range of options. “Not a lot of patients will say right off the bat, ‘I don’t want reconstruction.’ Many just don’t know,” she said.

“I am very fortunate where I practice that I have several plastic surgeons I can refer to, who are skilled at breast reconstruction,” Dr. Attai noted. She practices in suburban Los Angeles and estimates “probably about 80% or 85% of my patients get reconstruction.” That correlates with a study cited in The New York Times that found 63% of women who are candidates for the procedure have it, but in some parts of the country it is closer to 80%.

Noting that there is wide variation across the country and across medical practices in options offered to patients with breast cancer, Dr. Attai continued, “I like to think that the majority of my breast surgery colleagues, especially members of the American Society of Breast Surgeons, are doing the same thing that I am. We’re listening to our patients, giving them the options, and helping to guide them, rather than saying, ‘This is what you need to do.’”

Comfortable With Decisions

After thorough discussion, patients who choose not to have reconstruction “often seem to be very comfortable with their decisions,” Dr. Attai said, “but patients who undergo reconstruction can seem very comfortable with their decisions as well. It is really all about hearing a patient out, making sure she has had the chance to get her opinions, and going through the pros and cons of both approaches in as unbiased a way as possible. Some physicians may make the assumption that a patient will ‘do better’ with a certain approach, and I just don’t think it is our job to make that judgment for the patient.”

Physicians should also “let the patient know that this is not an emergency,” Dr. Attai advised. “I tell my breast cancer patients this is a mental emergency, not a medical emergency, and reinforce that they do not need to make a snap decision in most cases. Take your time. Get your options. Talk to your friends, your family, your loved ones, the people who are supporting you. Get second or third opinions if you want. I think when the physician gives the patient that permission, it takes a little bit of the urgency away from it.”

‘Not a Simple Process’

As Dr. Attai noted in The New York Times, “Reconstruction is not a simple process.” Most of the time, reconstruction involves two surgeries, a mastectomy with tissue expanders and a second procedure for the implant placement, she noted. Sometimes up to four surgeries are needed to complete reconstruction.

Selected patients may have direct implants, put in at the time of mastectomy rather than first using tissue expanders. That can only be done for a small segment of those eligible for reconstruction. These would usually be patients with smaller breasts, “not wanting to go larger, nonsmoker, nondiabetic, overall healthy, and with skin in good condition,” Dr. Attai explained.

“You can always go back and do reconstruction later,” she added, but with current techniques, “we have the ability to do the so-called ‘hidden scar technique,’ or nipple-sparing surgery, and if you don’t do immediate reconstruction, you lose those options and are left with the straight scar across the chest, not nipple-sparing.” In addition, reconstruction “is a little more challenging if the patient needed radiation, and that sometimes limits the options,” Dr. Attai stated, “but it can be done at any time.

Photographs accompanying the article in The New York Times depicted women who had both breasts removed, but Dr. Attai said that in her practice, most women who opt out of reconstruction still have one breast. “A few patients—if they are very large-breasted on the other side—might have a reduction on the other side,” she said.

Setting Realistic Expectations

According to the article in The New York Times, “For years, medical professionals have embraced the idea that breast restoration is an integral part of cancer treatment.” The Times article also suggests that some physicians minimize the complications while setting unrealistic expectations of what reconstructed breasts will look and feel like, which enrages some women who have not been pleased with the results. Dr. Attai noted she believes the plastic surgeons she works with do set realistic expectations but added that there is a great deal of variation in practice across the country.

“We’ve got great reconstructive options,” and some women who choose reconstruction will say that their reconstructed breasts “are better than they were before, but I certainly understand why many women will take offense at that,” Dr. Attai said. “We do have to be careful about overpromising,” she added. “The literature does cite a reasonable complication rate from these procedures, and while the majority of our patients will do very well, some will have these complications.”

Some complications could be those that might occur with any surgery, such as infection and bleeding. Complications more specifically related to reconstruction include loss of the implants, flap necrosis, nipple necrosis, pain, and muscle issues if the implants are placed under the muscle.

“Some patients never get comfortable with the feeling of the implants. Plastic surgeons are doing more autologous flaps and fat grafting. Patients can sometimes develop painful fat necrosis or lumps that we have to monitor or biopsy. There are a whole host of potential problems that can happen,” Dr. Attai said. ■

Disclosure: Dr. Attai reported no potential conflicts of interest.

References

1. Rabin RC: ‘Going flat’ after breast cancer. The New York Times, October 31, 2016.

2. Attai DJ: Treatment for breast cancer. Available at http://drattai.com/areas-of-focus/treatment-for-breast-cancer. Accessed November 9, 2016.