Women who are diagnosed with ductal carcinoma in situ (DCIS) frequently have lymph nodes removed during breast cancer surgery, even though medical guidelines recommend against it.
Studying the health records of 35,591 DCIS patients who were treated with either lumpectomy or mastectomy between 2006 and December 2012, researchers discovered that 29% of the women had lymph nodes removed during surgery: 84 had sentinel node biopsy (SLNB), while 16% had axillary lymph node dissection (ALND). SLNB removes one or two underarm lymph nodes; ALND removes several or all underarm lymph nodes.
Sampling lymph nodes is standard-of-care to stage the progress of invasive breast cancers: invasive ductal carcinoma, invasive lobular carcinoma and inflammatory breast cancer. Lymph nodes are removed and examined microscopically to help to determine whether the cancer has progressed beyond the breast, and the best treatment protocol.
Nationally recognized guidelines of both the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend against lymph node dissection in women who have DCIS that is treated with lumpectomy (the guidelines are less clear for DCIS-related mastectomy). No benefit has been associated with lymph node removal related to non-invasive DCIS, which typically remains within the breast. Guidelines recommend SLNB only when the suspicion of invasive breast cancer is high or when invasive breast cancer is discovered during surgery—as it is in about a fourth of women with DCIS who were originally diagnosed by a core biopsy.
In this study, researchers concluded that:
- 29% of the women studied had lymph nodes removed: 84.2% by sentinel lymph node biopsy (SLNB) and 15.8% by full axillary lymph node dissection (ALND).
- Among women who had mastectomy, 48% had SLNB and 15.2% had ALND.
- Among women who had lumpectomy, 16.7% had SLNB and 1% had ALND.
The study database reflected practices at more than 600 hospitals across the country, indicating that the trend is widespread. Most physicians included in the study were general surgeons; fewer than 5% were surgical oncologists. Surgeons who performed lumpectomy less often were more likely to perform some type of lymph node removal compared to high-volume surgeons—95% of studied mastectomies were performed by surgeons who operated for DCIS only once or twice a year. Why the concern?
What is most disturbing about this study’s findings is how often lymph nodes were removed from DCIS patients, despite nationally recognized guidelines to the contrary. Aside from an additional 2-3” incision, numbness in the armpit, increased risk for infection, and added time under general anesthesia, the issue is significant for another reason. Removing lymph nodes frequently compromises the lymph system, which carries excess fluids and bodily debris away from the tissues. Removing lymph nodes can impair this functionality, leading to lymphedema, mild to pronounced swelling that results when fluids don’t drain adequately and back up in the tissues.
The risk for lymphedema rises with the number of lymph nodes removed; sentinel node biopsy carries less risk of disrupting normal lymph function than a full axillary dissection. Once lymphedema develops, it becomes a lifelong condition that must be carefully managed to keep symptoms from becoming severe.
If you’ve been diagnosed with DCIS, be sure to discuss the extent of your surgery with your physician.
Reference: Coromilas E, Wright JD, Huang Y, et al. "The influence of hospital and surgeon factors on the prevalence of axillary lymph node evaluation in ductal carcinoma in situ." Journal of the American Medical Association Oncology
(2015); DOI: 10.1001/jamaoncol.2015.0389.
Once considered by Western medicine as a wacky approach to healing, acupuncture is now recognized by physicians (and most health care insurers) as a credible and effective treatment for symptoms of many types of health issues.
Studies show that acupuncture can relieve numerous types of pain, including back pain, chronic myofascial (facial) pain, neck pain, osteoarthritis in the knee, and even pain in the muscles and joints. A new study from the Mayo Clinic has found that acupuncture effectively reduces anxiety and pain after mastectomy
and breast reconstruction
Twenty breast cancer patients who had mastectomy with or without breast reconstruction participated. Needles were applied by a licensed acupuncturist with a Master’s degree level of training. For purposes of the study, a set protocol of 10 acupuncture points outlined by Traditional Chinese Medicine was used to address post-operative headache, nausea, vomiting, gastrointestinal pain, and musculoskeletal pain. Other acupuncture points also induced a calming effect to reduce patient anxiety.
All study participants were satisfied with post-op acupuncture and considered it to be worthwhile.
Women who participated in the study were taking either tamoxifen or anastrozole, anti-estrogen therapy to treat breast cancer; these anti-estrogens have a tendency to cause hot flashes, which can be frequent and strong. After 12 treatments over four weeks based on Traditional Korean Medicine acupuncture, all of the study participants reported a 70 to 95 percent reduction of the intensity of hot flashes, and overall, fewer hot flashes. In addition, the total number of hot flashes per patient reduced significantly.
Researchers concluded that acupuncture “significantly improves symptoms of postoperative pain, anxiety, and tension, and demonstrates a trend toward improved postoperative relaxation
.” Researchers also noted that “acupuncture can be integrated into a busy postsurgical clinical practice
” and “acupuncture may be an important intervention in the postoperative setting for breast cancer patients
Study reference: Mallory MJ, Croghan KA, Sandhu NP., et. al. "Acupuncture in the Postoperative Setting for Breast Cancer Patients: A Feasibility Study." The American Journal of Chinese Medicine
43, no. 01 (2015): p. 45-56.
Women who are 65 or older are often thought to be at more risk for complications after breast reconstruction, but a new study shows that isn’t necessarily the case.
Analyzing records for 40,769 women who had unilateral mastectomy between 2005 and 2012, researchers identified 15,093 women who were age 65 or older at the time of their surgery; almost 11% of these older women had breast reconstruction, compared to 39.5% of mastectomy patients who were younger than age 65.
When researchers compared 30-day complication rates between the two age groups, they found:
- complication rates were similar among women who had reconstruction with breast implants.
- for the most part, rates of post-surgical complications after autologous tissue flap reconstruction (with a woman's own natural tissue)—longer hospital stays, more frequent complications, and more re-operations—was similar: about 7% of the older women developed post-surgical complications after breast reconstruction, compared to about 5% of younger women.
- women in the 65+ group who had autologous reconstruction were more likely to suffer venous thromboembolism than their younger counterparts.
Venous thromboembolism (VTE) is a blood clot that forms in the leg or lung that breaks loose and travels in the blood. Overall, the rate of VTE among women who had autologous breast reconstruction was just 1%. Women who were 65 and older developed VTE 4 times more often than their younger counterparts; women between ages 70 and 75 developed the same problem 6 times more often.
Study authors suggested that, "Older patients should be counseled that their age does not confer an increased risk of complications after implant-based post-mastectomy breast reconstruction. However, they should be counseled that their age may confer an increased risk of VTE.”
The somewhat higher risk of VTE doesn’t necessarily preclude older women from having autologous breast reconstruction, but it does indicate that more precautions, such as the use of blood-thinning medications, should be taken with older women.
Source: Butz DR, Lapin B, Yao K, et al. “Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction.” Plastic and Reconstructive Surgery. 2015 Feb; 135(2):253e-61e.
The National Comprehensive Cancer Network, a consortium of the nation’s leading cancer experts, and the American Society for Clinicial Oncology set national guidelines for treating various cancers. Both groups recommend post-mastectomy radiation therapy for women with locally advanced breast cancer (cancer cells in 4 or more lymph nodes). Radiation is a crucial part of treatment for these women, because it greatly reduces recurrence and improves survival.
A new study, however, shows that only 65 percent of women who meet these guidelines actually have recommended radiation.
Using the National Cancer Data Base, researchers at Louisiana State University examined the medical records of 56,990 women who were diagnosed and treated for with N2/N3 breast cancers between 1998 and 2011. They were surprised to find that 35 percent of the women did not have recommended radiation after mastectomy; the study authors had expected a much higher rate of compliance.
But why wouldn’t women who are at high risk for recurrence and potentially life-threatening consequences follow through with a recommended treatment? None of the following factors seemed to independently influence compliance or noncompliance:
- average age was 58 years
- 96% had health insurance
- 98% resided in urban communities
- 83% had no co-morbidities (medical conditions that would preclude having radiation)
- 82% received chemotherapy
- 81% were Caucasian
- 59% were from a comprehensive community cancer programs
Only three factors were associated with compliance: being alive 30 days after surgery, being readmitted to the hospital within 30 days of surgery, or having chemotherapy (women who were treated with chemotherapy were 5.4 times more likely to have radiation therapy). These were statistical factors—none of the women were actually interviewed. The researchers could not tell from the medical records whether patients were unaware of their need for radiation therapy, if they refused it, or what their reasoning might be, indicating a need to additional research.
Source: Chu QD, Caldito G, Miller JK, et al. “Postmastectomy radiation for n2/n3 breast cancer: factors associated with low compliance rate.” Presented at the Southern Surgical Association 126th Annual Meeting, Palm Beach, FL, November 30–December 3, 2014. (http://www.journalacs.org/article/S1072-7515%2815%2900025-3/abstract
If you’ve had a mastectomy
followed by reconstruction, should you continue having mammograms? The answer is generally no, but maybe, depending on your circumstances.
Mammograms are recommended to detect early breast cancers; since almost all breast tissue is removed during mastectomy, mammograms are no longer required. Breast reconstruction doesn’t affect breast cancer recurrence or new tumors, so it doesn’t influence whether or not you should have continuing mammograms. Your mastectomy, however, does. The American Cancer Society recommends that “women who have had total, modified radical, or radical mastectomy for breast cancer need no further routine screening mammograms of the affect side (or sides, if both breasts are removed).”
Annual mammograms are
advised for women who:
- have unilateral mastectomy--routine mammograms are recommended on the healthy breast.
- had a subcutaneous mastectomy (an outdated type of nipple-sparing mastectomy that left breast tissue at the base of the nipple).
In some cases, your physician may recommend post-mastectomy imaging:
- a baseline mammogram after breast reconstruction so an unusual area that develops can be scanned and compared.
- a mammogram, ultrasound or needle biopsy to determine whether a lump in your reconstructed breast is scar tissue, necrosis (a hardened area where fat cells have died), or something more suspicious.
- periodic mammograms or MRIs if you have an inherited BRCA mutation or a strong family history of breast cancer that puts you at high risk for recurrence (the value of mammograms and MRIs in this case hasn’t been proven, but some physicians do recommend extra surveillance for high-risk women).
Breast reconstruction with silicone implants
is an exception to the screening-after-mastectomy rule, but it is meant to check for possible “silent ruptures,” rather than detect breast tumors. The FDA recommends MRI screening of silicone implants 3 years after silicone implants are placed in the chest, and every 2 years following, for as long as the implants remain in place. (This isn’t recommended for saline implants, which deflate when they leak or rupture.) Insurance doesn’t usually pay for these MRI screenings, but they are important, since a ruptured silicone implant may not cause any visible symptoms.
After mastectomy with or without reconstruction, you should continue to monitor your breasts with monthly self-exams and an annual clinical exam by a health care professional.
Before (left) and after (right) immediate stacked DIEP flap reconstruction of left breast and lift of opposite breast. Images provided by Dr. Frank J. DellaCroce and The Center for Restorative Breast Surgery, LLC.
If you’re having unilateral mastectomy
—removal of one breast—to treat breast cancer, and you would like to have that breast reconstructed, you have three alternatives from a cosmetic perspective.
Your healthy breast can be:
- Modified. The size of your remaining breast can be enlarged with a breast implant, reduced and/or lifted. This option gives your breast a makeover that you might have been otherwise reluctant or unwilling to do, and combined with breast reconstruction, your “girls” may be made bigger or smaller and positioned back where they used to be.
- Removed and reconstructed. If you have a high risk for contralateral breast cancer (cancer in the opposite breast), your oncologist will probably recommend that you consider removing your healthy breast as well to reduce your risk of developing a future breast cancer there. If you make this choice, you’ll have bilateral, rather than unilateral mastectomy, and both of your breasts can be reconstructed at the same time. From a cosmetic perspective, this is the best likelihood of a better match of size, shape and position, with nipples that are equally centered.
- Left alone. Of course, you always have the option to leave your remaining breast exactly as is. If you prefer not to have it surgically altered, your plastic surgeon will try to match your reconstructed breast as closely as possible. Your breast can be recreated with an implant or your own tissue. If your healthy breast has given in to gravity, however, building the missing breast with a tissue flap reconstruction using your fat is the best choice for a good match, because the living tissue can be shaped to conform, while a breast implant cannot.
Autologous (tissue flap) breast reconstruction
is a fancy term that means using your own tissue to rebuild breasts after mastectomy. Fat and skin (and sometimes muscle, depending on the surgical technique and surgeon’s skill) can be taken from just about anywhere you have too much of it.
The abdomen (DIEP
procedures) is the most common source for autologous breast reconstruction, because that’s where many women have excess fat that they would love to see minimized or disappear altogether. Other fat sources for breast reconstruction include the upper or lower buttocks, and the inner thighs, another area where we women tend to collect deposits of hard-to-get-rid-of fat.
If you’re interested in autologous breast reconstruction but you’re blessed with a fit and trim tummy, your “love handles”—the outer hips just above the buttock—may provide adequate volume for your reconstructed breast.
The Lumbar Artery Perforator (LAP) flap uses fat and skin from the hip, without sacrificing muscle. Removing a flap of tissue from this area leaves a horizontal scar where the waist meets the upper buttock. Hip flaps can also be combined with flaps from the abdomen or other areas to produce the overall desired breast volume.
Some interesting notes about LAP flaps:
- Because the muscle isn’t removed or divided, recovery is somewhat quicker and less painful than tissue flaps that harvest muscle.
- The procedure slims the hip area (a bonus!), which can be difficult to reduce with diet and exercise.
- The resulting scar can usually hidden by most underwear and bathing suit bottoms.
Because most plastic/reconstructive surgeons do not perform LAP procedures, one of the most difficult aspects of choosing a LAP flap is finding a plastic surgeon
who has the skill, expertise and experience to do it.
Women who have breast reconstruction
with saline or silicone breast implants
sometimes develop rippling, the appearance of visible ridges or wrinkles in the implant that show through the skin. Rippling usually develops on the outer perimeter of the reconstructed breast: on the side, bottom or in between the breasts. It may be especially visible on the top of the breast when you lean forward. It is more likely to be visible in very thin women. What Can Be Done About Rippling?
Unfortunately, massaging, exercising or special skin products cannot get rid of rippling. In most cases, correcting the problem involves a trip back to the OR for revision surgery with one of the following fixes. Replace the implant.
Swapping out an implant sometimes eliminates rippling:
- Opt for a larger size. Implants that are too small for the pocket under the muscle can shift until they settle at the bottom of the breast, creating less volume and potentially more rippling at the top. This is often the case when the pocket is too large for the implant, or the remaining breast skin is very thin or damaged.
- Switch to silicone. Silicone implants ripple less than saline implants; this is particularly true of cohesive gel "gummy bear" silicone implants that fill out the shell more smoothly and consistently than less viscous forms of fillers.
- Replace textured with smooth. Textured implants are designed to minimize capsular contracture and to keep teardrop-shaped implants in place so that they don’t move around (or tip over) in the pocket. The roughened surface stabilizes the position of the implant by sticking to tissue (somewhat like Velcro), and that can cause rippling. Add more saline.
All saline breast implants, regardless of size, shape or model, have a recommended minimum and maximum amount of saline that should be added. (Silicone implants, on the other hand, are filled and sealed at the factory and cannot be altered.) An implant, for example, may have a recommended fill range of 300-330cc. Adding 300cc will create a softer breast, but also increases the likelihood of developing ripples, wrinkles, and folds in the implant shell, and that can eventually cause the implant to rupture. Adding 330cc is less likely to create rippling but will result in a breast that is not quite as soft. In this example, “underfilling” (adding less than 300cc) or “overfilling” (adding more than 330cc) may cause the implant to fail, and may void the manufacturer’s warranty. Add an acellular dermal matrix.
Covering the areas of rippling with a layer of acellular dermal matrix
(e.g., AlloDerm or Strattice) creates an additional barrier between the implant and the breast skin. Reposition the implant.
Unlike implants that are used for augmentation and can be positioned either in front of or behind the muscle, implants used for breast reconstruction are almost always placed under the muscle, since the breast tissue has been removed. A few recontructive surgeons (very few!) prefer to place breast implants over the muscle. In this situation, rippling that develops may be improved or rectified by repositioning the implants beneath the muscle. Add some fat.
Depending on the circumstances, a few small injections of fat liposuctioned from hips, thighs or stomach can make ripples less noticeable.
A newly-published study in the January issue of Plastic and Reconstructive Surgery (the official medical journal of the American Society of Plastic Surgeons) found that women who have breast reconstruction with their own tissues are more satisfied than women who have reconstruction using breast implants.
Although the study wasn't large--just 92 women who had reconstruction between 2006 and 2010--it's not the first time that women have expressed greater satisfaction when they have natural tissue reconstruction. This type of surgery is certainly more intensive, invasive and requires a longer recovery than reconstruction with implants, but it also produces breasts that look and feel more natural and don't have the inherent problems that come with breast implants (including eventual replacement).
In this study, 47 women had natural tissue reconstruction; most used their own abdominal tissue to recreate their breasts. The remaining 45 women had breast implants.
Here are some key results
(based on a 100-point scale) and differences between the two categories of women:
Natural tissue reconstruction:
- Average age: 51
- Average overall satisfaction with breast reconstruction: 82
- Average satisfaction with reconstructed breasts: 75
- Reconstruction delayed an average of 21 months after mastectomy
- More likely to have radiation therapy
- Higher average body weight
Breast implant reconstruction:
- Average age: 44
- Average overall satisfaction with breast reconstruction: 74.5
- Average satisfaction with reconstructed breasts: 65.5
- Reconstruction performed immediately (with mastectomy)
- Women were more likely to have bilateral reconstruction. (Many chose preventive double mastectomy to lower their high risk of breast cancer due to a BRCA gene mutation.)
Study authors emphasized that both methods of breast reconstruction provided good outcomes, with similar scores for quality of life, and that complication rates were similar between groups, although the natural tissue reconstruction group had a higher rate of secondary corrective surgeries.
Discussions about whether or not women should have breast reconstruction after mastectomy are like politics: everyone has an opinion.
Navigate around the Internet for a bit and you'll find vehement blogs against reconstruction, arguing why women should stay flat after mastectomy. You'll also find the polar opposite view: strongly-worded positions in favor of breast reconstruction.
As women, we are all different. We have different goals, different likes and dislikes, and decidedly different
opinions of what is right for each of us. Some of us feel the breast reconstruction journey is worth the effort, and that is just fine. Others consider it a waste of time and effort, and that is also fine, because what is right for one isn't necessarily right for all.
Breast reconstruction is a deeply personal decision, no matter what the outcome. For many of us, the decision is an easy one, whether we decide to have our breasts recreated or not. For others, it's an emotionally difficult and confusing decision, and the answer doesn't always come easy.
Probably the best thing about breast reconstruction is that it is an option
, meaning that each of us has the right to decide whether or not we want to have it, without others second-guessing or condemning our decisions. And that's why I appreciated "Why I Don't Miss My Breasts Anymore
" by Kansas poet laureate Caryn Mirriam-Goldberg, as featured earlier this month on the Huffington Post.
What is especially noteworthy about this post isn't that the author lost her breasts, chose not to have them rebuilt, and is okay with that decision, but how eloquently she speaks for us to understand and respect the decisions of others who find themselves in the same situation.
Breast reconstruction is not always a quick or easy decision---nor should it be. It should be the thoughtful result of carefully gathering information, understanding your options, and then (and only then) making an informed decision about what is right for you.