Monday, July 30, 2007

The Old Man and the C

I expressed this particular opinion on another medical site, and was -- gently -- told I was an old guy, of a generation that was out of touch. It could be true. But having treated many hundreds of women with breast cancer (I lost count a long time ago) and having been (so I was told) more sensitive to the horror and fear than the "typical" surgeon, I feel qualified to express myself. My thoughts are based in the reality I saw in my practice. So here it is: though not opposed, and having participated in many cases of it, I'm not a big fan of immediate breast reconstruction after mastectomy.

As I recall, the thread in which I commented on that other site was regarding yet another study showing that surgeons had a poor record of offering reconstruction to their mastectomy patients. Of that I was never guilty. I think it's wonderful that it's available. It's a timing thing, to me. To my patients undergoing mastectomy, I always brought up breast reconstruction; among other things, I made sure they understood it was not considered "cosmetic," and was (by law!) covered by insurance. I discussed both immediate and delayed reconstruction, and did not try to talk women out of the former choice if that's what they preferred. But I was glad when they didn't. At the risk of being misunderstood, let me try to explain.

The blanched face, the terrified glaze of the eyes, the tears. The jumbled words cascading past a trembling jaw, the grip of hand upon hand, fingers compressed white and shaking. Witnessing thoughts tumbling almost visibly through the mind, randomly, out of control, one, two, three after another, splashing through pools of panic. Endlessly, I've seen it, over and over, to the point of hating it above all, to the point of looking at my schedule and feeling a physical tightening in my gut when I saw such a consultation there. That's the reality in which such conversations take place. No matter how carefully, how gently or insistently; despite taking time, providing reassurance that we can deal with it, handing out personally-written booklets; my attempt at informing, explaining, supporting the woman and her family to whom I give the news often feels futile, as I try to breach the wall of stunned disarray.

Mastectomy is always a treatment option for breast cancer. As understanding has evolved, it's uncommon that it's the only one. By far the majority of women undergoing treatment for breast cancer have the option of breast preservation, via lumpectomy and radiation therapy. For reasons I've dealt with before (here, plus 1, 2 , 3 , 4 following), some choose -- or need -- mastectomy. More than any other cancer, I'd say, there are branching decision trees to be understood, choices to be made: lumpectomy vs. mastectomy, how and where radiation fits in, when and what kind of chemotherapy is used, the need for lymph node sampling, when and if full axillary dissection would be used instead of or in addition to sentinel node biopsy. And for women who will undergo mastectomy, the issue of prosthesis vs. reconstruction: what type -- among many varieties -- and when. It's a lot to assimilate.

So my first concern is simply about overload: the need to wade through an enormous amount of information and sort it all out, at a time when you are bordering on panic. In the midst of that, adding another very thick layer of fog, requiring visits to a plastic surgeon and the full consideration of several very different options, making a realistic decision about reconstruction seems, sometimes, like piling on. First things first. Let's focus all our energy on getting through the cure. Let's know that this option awaits, and be reassured by it; and get back to it later.

I suppose that sounds condescending. Poor little women, can't handle all that stuff. Hardly. Women are tough as nails. They have to be. And let me say again: I've always brought up, and haven't tried overtly to steer women away from immediate reconstruction. (Does my mind-set affect the outcome? Could be, in some cases.) But condescension (if that's what it is) cuts both ways. At least one famous female surgeon used to go around the country claiming that the only reason mastectomy was invented was because men like to mutilate women. And, by inference, a woman who'd choose it, and not have reconstruction, was somehow succumbing to that mindset. Mastectomy is mutilation. But how one responds to it is -- and ought to be -- very individual. The time, it seems to me, to decide about reconstruction is after the enormous stresses of facing the cancer are dealt with. Many major centers publish with pride that immediate reconstruction is their standard of care, their treatment of choice. I can't help but think that many women are pushed (is that too strong a term?) into it when they'd rather just take their time.

Depending on the method, breast reconstruction is a very big deal. The operation can take several hours, and may subsequently require a couple of much smaller touch-ups. Clear-headed choice is mandatory. And here's a related issue: lying in an operating room for another four hours -- turning a forty-five minute operation into a five hour one -- anesthetized, then having one's body deal with all the required healing, while asking the body also to deal with as yet not-fully-treated cancer seems physiologically iffy. I know of one study that found no average delay in starting chemotherapy for women undergoing immediate reconstruction, and that's good. What haven't happened yet -- and likely won't, for practical reasons -- are studies that randomize women into immediate versus delayed reconstruction and follow for several years to evaluate any effect on long-term cure, segregated by stage at diagnosis. It'd be important, I'd think. Related are the delays from diagnosis to treatment that come with the need for arranging the consults and coordinating operating time. Maybe centers who promote immediate reconstruction have streamlined that part.

I don't for a second minimize the psychological effect of mastectomy. I've seen it. I know it. I've practiced through the times when reconstruction was not available; when it was technically disappointing, and when it became cosmetically fabulous; when it was done only later; and now, when it's done at the time of the mastectomy. In the pre-immediate days, I've had many patients who were very relieved to know reconstruction could be done yet who, when the time came, said they were surprised at how comfortable they were with their status and chose not to have reconstruction. (Prosthetics have also come a long way: some adhere directly to the chest so they don't need a special bra; they have lifelike texture and coloration; their nipples show through flimsy bras, if you like that sort of thing.) The numbers weren't small. From that fact, I infer that many women, under the stress of the initial diagnosis, are "encouraged" into a very big surgical deal when, given time, they'd have opted out. One can argue both ways whether that's a good or a bad thing.

Psychological well-being and body image are the bottom line issues (assuming -- which we can't quite -- no impact on survival). Studies make it clear that reconstruction serves the purpose very well, and argue for immediate reconstruction. Yet it's not simple: the "baseline" evaluations of immediate reconstruction were done in women not yet treated, who had no basis for knowing what mastectomy would be like for them; those of the women who underwent delayed reconstruction had already had mastectomy. The measured improvements were less in those with delayed surgery; but they'd had time to adjust and, in effect, raise that baseline.

I'm no crusader here. I neither expect nor desire to change minds. Recognizing that it's not clear-cut, rather than pushing a particular approach, I favor being sensitive to the individual; having feelers out to intuit what the woman sitting in front of me needs. But it appears that there's now a trend in a single direction, and that it's generated in academic centers -- the very places where, in all things, more is more. (If there's a more complicated means to an end, they find and promote it. Kidding [?]) Based on my experience, it's a steamroller for at least some women, generating what may be unnecessary anxiety and commitment to a very laborious and expensive process; forcing a quick decision at a time of great vulnerability.

When I've been asked my opinion, I've given it. When from behind those glazed eyes, from obviously overwhelmed minds the words are formed, "What do you think, doctor? Should I have reconstruction right away?" I've usually said something like this: "I have no problem with it if that's what you want to do. But if you don't want to have to decide now, you will always have the option, any time, down the road. Let's set up a consultation with a plastic surgeon if you like, to hear what's involved. But for now, let's go about curing breast cancer. Let's get all that over with, and when you're recovered, feeling good, strong, we'll take that one on and sort through the options." It's self-selecting, I'm sure: if they're asking, they're hesitant. But generally, when they hear that, a quantum of tension is dissipated, the grip relaxes, and you can sense a bit of relief fill the room.

Addendum: I'm well aware that most plastic surgeons prefer immediate reconstruction, because they don't have to deal with scar tissue. It's easier. Many claim better cosmetic results (I've seen it both ways, and -- at least with tissue-transfer techniques such as TRAM flap -- can't tell the difference. Both look great, usually.) Frankly, I think their ease is part of the push for immediate reconstruction, and I'm not sure it ought to be. Patient satisfaction is another issue, and like the whole subject is iffy and tricky and subject to claims of being patronizing. Recognizing the impossibility of accurately measuring such a thing and to subject it to a meaningful prospective study, I've heard opinions expressed on both sides of the issue by plastic surgeons. Some say that comparing a reconstructed breast to the "real" one -- which is what happens with immediate reconstruction -- has a higher chance of disappointment than when it's compared to having lived with mastectomy for a time. I'd welcome comments from my occasional plastic surgeon readers. And here is an example of what we're talking about, from the right side of the bell curve:


Klari said...

I'm a very new reader. If everything goes well, I should be taking a fresh start this fall, going back to university, to study... medicine. In France, because I live there, and because it's affordable here.
ANyway, I just wanted to say that I hope I will have teachers that profess careful and nuanced opinions, as you do.
Thank you for sharing your experience here.

Bongi said...

good set out arguement. as always there must be balance. i also get the feeling that the immediate reconstruction school is at least partly related th plastic surgeon comfort. just an impression.

Eric, AKA The Pragmatic Caregiver said...

Dr. S:

Is there enough difference in mastectomy technique between various surgeons that the underlying patterns of scar tissue would matter much in reconstruction? IE, does technique C, perferred by X% of surgeons, lead to a better aesthetic result with immediate reconstruction, vs. technique D, which results in better aesthetics if reconstruction is delayed, or is mastectomy technique quite universal between surgeons?


(as an aside, it seems like there's quite a difference in cosmetic outcome without reconstruction between surgeons, at least to my eye, and it doesn't look like it can all be explained by differing rates of keloid formation - some mastectomy scars look like the surgery was done with a Ginsu, and others where the scars follow a more natural line of the body).

Sid Schwab said...

klari: thank you very much! And good luck!

Eric: well, sort of, yes and no. Most people agree the best mastectomy scar is horizontal, both from the point of view of the scar itself, and for reconstruction. You can't always do it that way, for various anatomic and tumor reasons. With reconstruction in mind, you tend toward taking as little skin as possible; that's also in part dependent on tumor location. There's something to be said, on the other hand, for taking as much skin as possible in certain situations: more tension at closure makes for a more prominent scar. Some people (I hope it's the case in your experience) make more of an effort toward a "nice looking" mastectomy scar. I tried. Didn't always succeed. I was actually thinking of posting a few things about technique. There are a couple of tricks. I can say that I had a few patients come back to tell me when some professional or other (prosthetist, etc) saw them, they were told "oh you must have had Dr Schwab." In a nice way.

rlbates said...

Dr S,
As both a woman and plastic surgeon, I appreciate your post. It is nicely done. Also, thanks for finding a photo of a "great" reconstruction. I think it is an individual's choice. We should inform and support the patient. It is difficult not to influence them. You put it so well--it's human nature. It's hard (maybe impossible) not to somehow impose one's own bias. But what is "right" for one may not be for the "next" much less for "all".
The timing of reconstruction does not significantly hinder the detection of local recurrence of
cancer or the rate of local recurrence after 5 years as shown in repeated studies. So it comes down often to which the patient &/or surgeon(s) prefer. It has also been shown that it doesn't really make much difference in overall costs. Check out this article (and its references): Comparisons of Resource Costs and Success Rates between Immediate and Delayed Breast Reconstruction Using DIEP or SIEA Flaps under a Well-Controlled Clinical Trial by Ming-Huei Cheng, M.D. & others
(Plast. Reconstr. Surg. 117: 2139, 2006.)

Sid Schwab said...

rlbates: thanks. I was hoping for your input here.

Eric, AKA The Pragmatic Caregiver said...

As much as it pains me to say this, yes, I happened to find your work quite aesthetically pleasing relative to virtually everyone I've seen - thoracic surgeons have felt compelled to comment, in fact - which, as passionate of an advocate for my mother as I may be, is still a little discomfiting - think of being in school and having your slightly-precocious/obnoxious friend commenting on your mom's rack, only add 20+ years.

Please do post technique hints - your technique (and especially something about how you place the clips near the axillae) has provoked comments about aesthetics from a wide variety of People Who Know, including several prominent medical oncologists.

I'm of the belief that part of mom's (ridiculously) successful siege against breast cancer has been that she never felt like she was going through life freakishly bloated, maimed, or scar-covered.



Unknown said...

This was a beautiful post. If you are even half as sincere as you seem to be, the world is a better place for having you here. Thank you for being a gentlemen, and thank whoever has helped shape you into the man you are.

Jeffrey Parks MD FACS said...

Every plastic surgeon Ive worked with seems to prefer immediate reconstruction. I always bring up immediate reconstruction as an option when discussing the pre-op plan with women requiring mastectomy. I give them a couple of cards from plastic surgeons and let them make up their mind. I've been surprised by the number of women in their 80's who wanted to have reconstruction done. Never underestimate the importance of body image no matter what the patients age.

Margaret Polaneczky, MD (aka TBTAM) said...

This was a great post - I see a large number of patients who have had breast cancer, and the cosmetic results with current reconstruction is nothing short of amazing.

Dr. Rob Oliver Jr. said...


There's two competing things going on with the timing of reconstruction, one results oriented & one of convenience.

It clearly is much easier to get better results at the time of mastectomy when using tissue expanders. Skin contraction can largely be prevented by counter pressure of an expander. Delayed expansion will often signifigantly thin out the mastectomy flaps.

OTOH, immeadiate reconstruction can be riskier depending upon how the general surgeon performs the mastectomy. No offense, but I think many general surgeons (and I trained as one prior to Plastic Surgery) do not have a clear grasp about the formal anatomic boundries of the breast and frequently mistake subcutaneous fat for breast tissue. There is no biologic reason to violate the inframammary fold, take the pectoralis fascia, or extend the superior or lateral disections into the axillae in almost any instance. All those manuevers compromise reconstruction uneccesarily.

We now know that immeadiate reconstruction on obese or diabetic patients carries extremely high rates of complications as does reconstruction on patients who later recieve XRT unexpectedly.

Sid Schwab said...

Rob: I appreciate your thoughts. The immediate reconstructions in which I participated were all with the same plastic surgeon, who assisted me with my part (I stayed once or twice for his, but generally wiggled out of it when I could!). He always said I should do it the way I wanted and made no anatomic requests. When I could I left more skin than I might have. He sometimes looked a little worried if he thought I was getting too thin (I wasn't). He liked to do free flaps with micro anastomosis. Whereas I frequentlly left the inframammary fold alone, I generally took the fascia -- some parts of training are too ingrained to reject. I guess I haven't seen the literature that says it's ok to leave it. In general I've been nothing but impressed with the results, immediate or delayed. There was one failure of the entire graft after his anastomosis, and that led to a lot of misery, followed by full recovery.

Anonymous said...

I was recently diagnosed with BC in my 30s. Because the whole breast kind of went bad (big multi-focal ductal tumors and a handful of lobular thrown in), mastectomy was the only option.

I was told immediate reconstruction via pediculed TRAM was my best option. I asked my surgeon about the "free flap" surgeries, but was basically told by my surgeon that they were "experimental" and unreliable.

Mind you, I live in Los Angeles, within spitting distance of UCLA.

I did the pediculed TRAM, and will regret it until the day I die. I have since found out that UCLA does hundreds of free flaps every year, with as good a success rate as pediculed TRAMs. I not only lost my breast, I gave up a perfectly good muscle for NOTHING. It's that loss I feel most profoundly. I could care less about the evil breast. I want my muscle back. I am very active and feel very compromised from this surgery.

Why was I pushed into this? Shouldn't my surgeon have urged me to get a second opinion at UCLA after I asked about the free flap?

Dr. Rob Oliver Jr. said...

Pedicaled TRAM's are the gold-standard for reconstruction and are in general well-tolerated.

"Free" TRAM's using microsurgery still sacrifices the function of the muscle and offer little real benefit except in those more likely to have blood flow problems with a pedicled TRAM (smokers, diabetics, obese).

"Perforator flaps" (aka DIEP or SIEP flaps) disect out the 1-2mm vessels thru the rectus muscle and do try to leave the muscle behind. They are very complex & finicky operations and not performed widely outside of teaching hospitals. A number of surgeons feel the orientation you must put the tissue into to inset these free flaps gives inferior cosmetic results.

In the future with socialized medicine, I expect such exotic operations for breast reconstruction to be much less funded (and thus less performed). The dramatic cuts in reimbursement (75-80%) for autologous recontruction have made tissue expander-implant reconstruction the much more prevalent method

Anonymous said...

Dr. Oliver: thank you for posting. You made me feel much better. In hindsight, I would have done a bilateral (for cosmetic as well as risk reduction reasons) DIEP with Dr. Watson at UCLA. They seem to have great cosmetic results with less loss of muscles.

Pursey Tuttweiler said...

While I know it is mutilation, a mastectomy patient does not look mutilated to me, they look healed. I know it is a big, big, big, deal. Someone I love dearly did lumpectomy after lumpectomy in order to save her breasts because she adhered to the mindset that mastectomies were performed needlessly and she was not going to let anyone mutilate her. Now she has stage 4 breast cancer in her bones, her brain and her liver. I know another woman who told her surgeon, the minute she consulted with him, "Take everything. She pointed to her heart and her head and said, "This is me. These breasts are not who I am." I would take her approach. However, if faced with this decision, I would seek out the most highly recommended surgeon possible.

Pursey Tuttweiler said...

While I know it is mutilation, a mastectomy patient does not look mutilated to me, they look healed. I know it is a big, big, big, deal. Someone I love dearly did lumpectomy after lumpectomy in order to save her breasts because she adhered to the mindset that mastectomies were performed needlessly and she was not going to let anyone mutilate her. Now she has stage 4 breast cancer in her bones, her brain and her liver. I know another woman who told her surgeon, the minute she consulted with him, "Take everything. She pointed to her heart and her head and said, "This is me. These breasts are not who I am." I would take her approach. However, if faced with this decision, I would seek out the most highly recommended surgeon possible.

Elizabeth said...

I had bi-lateral mastectomy and immediate recon with tissue expanders and later silicone implants. I believe it was the right choice for me. I got it all over with and am happy with the outcome. I believe that the reconstruction process would have been more painful and with worse cosmetic outcome if I had waited. My sister had implant reconstruction about a year after mastectomy and it was very painful because she didn't have the benefit of skin sparing mastectomy. There was much more to stretch a year later.

You narrate the experience of being told you have breast cancer very well. If my surgeon then had said what you say -- "I have no problem with it if that's what you want to do. But if you don't want to have to decide now, you will always have the option, any time, down the road. Let's set up a consultation with a plastic surgeon if you like, to hear what's involved. But for now, let's go about curing breast cancer. Let's get all that over with, and when you're recovered, feeling good, strong, we'll take that one on and sort through the options."

I would have felt that you were pushing me not to have reconstruction, that the immediate reconstruction would have been impeding on my ability to fight the cancer. I wouldn't have done it, and for no reason other than guilt that I was putting appearances before fighting the cancer.

Maybe I am wrong and you are having this conversation with old ladies. I was only 32 whe I had to have the talk.

Sid Schwab said...

elizabeth: thanks for your comment. I think the salient point in my post was that "I favor being sensitive to the individual; having feelers out to intuit what the woman sitting in front of me needs." So the conversation of mine that you quote was specific to when I was directly asked what I thought. I didn't have a speech I gave to all women, or even some women. I tried to be sensitive to their needs. Many of my patients had immediate reconstruction. In some cases, when my patients couldn't make up their mind and wanted me to direct them, what you quote is often how I responded.

I'm pretty sure the day will come when all this is moot; when cancer of all types will not require extensive operations because ways of attacking cancer cells directly, without harm to healthy cells, will have been found.

Anonymous said...

So glad I came across your blog. I am a Canadian Nursing student and I have to say how great it was to read about your true care for women with such a diagnosis. You seem to have an amazingly true empathy for the holistic effects of this disease; I can imagine the extent of the positive impact that these surgeries must have on your patients lives, thank you for your genuine holistic health care and for giving so much to the women you treat. "Old Man"? I think not.

Sid Schwab said...

Thanks for your comment; and I'm glad you found the blog.

Angie said...

Dr Sid,

I do not know who told you that you were old and out of touch but they would do well to learn from you and absorb some of your insight into the disgusting and disfiguring disease of breast cancer. I happened upon your post and was amazed as I read your account of the horror of a breast cancer diagnosis. I never really thought of the whole process from a surgeon's viewpoint and having to face patients over and over knowing that you have to give such horrible and frightening news. There are very few who are as eloquent and sensitive as you are. Your account was spot on and it made me remember how frightened I was.

I was diagnosed with Stage 3A Triple Neg Breast Cancer two years ago. I elected to have a bilateral mastectomy because I didn't want to worry about it coming back on the unaffected side and I felt it would be less traumatic to have both breasts gone rather than just one. I am now at the point of considering reconstruction and have decided to have the SIEP flap surgery. At the time of my mastectomies, I was told that immediate reconstruction was not possible as I was going to have to go the full course of chemo and rads. Looking back at it all now, it would have been nice to have immediate reconstruction rather than facing the grizzly scars that took over the spot where my breasts had once been. I would like to think I took the entire process in stride but I plainly remember the sight of my scars when I took the dressings off for the first time and it brought me to my knees. Having said all of that, while I am really looking forward to reconstruction, I am glad that I waited and gave myself time to heal both mentally and physically. I am hopeful that the outcome will be much better since I have waited.

Sorry if I have rambled overmuch, I just wanted you to know that I was very impressed with your post. Your patients are very fortunate to have you. Thank you for being a kinder, gentler, more caring physician.

Sid Schwab said...

Angie, thanks for your comment. You've been through a lot, but it sounds like you're coming out the other end of the journey in good shape. I wish you well.

redhawk said...

I found your blog by way of a completely unrelated Google search- and I'm so glad I did!

I want to thank you for blogging about your experiences performing breast cancer surgery. It's so helpful to hear what it's like from the surgeon's point of view! Thank you for your service to women with breast cancer over the years. :)

I was diagnosed after stereotactic & ultrasound-guided biopsies with IDC in the left breast and DCIS in the right. I had a double lumpectomy on 9/1/09 and aside from a seroma in the left SNB site, I have been recovering well since then. My Oncotype DX score is not back yet. I am still hoping to avoid chemo. My father and my uncle both died of leukemia. I read that leukemia can be caused by chemotherapy, although the risk is very low, which is the reason I'm hoping for a low Oncotype score.

I want to say thank you again for this blog! My breast surgeon was great but he sometimes seemed like a bird that popped out of a cuckoo clock for a few minutes to check on me each week following my surgery and then disappeared behind his little door again. He would answer all my questions and I know he really cared about all his patients but he always seemed a little stressed and pressed for time. My father was a surgeon too, so I completely understand that.

Thanks for bridging the doctor-patient gap. You are dong a wonderful job! :)

Sid Schwab said...

Thanks for your words, redhawk, and I wish you well in your recovery.

Esmeralda Designs said...

Dr. Sid-
Much thanks for your eloquent post that I found preparing for my skinsparing bil MX next week due to DCIS in 2 sites right breast and a heavy familiy history of breast and prostate cancer. Waiting for outcome of genetic testing but will have the bil MX no matter what. Too much risk involved.

Had a most impersonal very chilling meeting w/my plastic surgeon and even though my reconstruction with expanders and subsequent implants are what I envisioned before meeting my surgeon since I am rather slender I am feeling that I was not able to fully understand if my options also include a direct-to implant option via an alloderm matrix hammock.

I simply did not feel he cared for my self esteem and integrity, and had my best interests in mind. Unfortunately, I don't have an option to talk to another surgeon because scheduling issues at my hospital.

I talked to my GP afterwards and she said that perhaps the coolness of the plastic surgeon was due to him knowing what he had to do to a on the outside healthy beautiful chest. And that things might improve during the expansions and subsequent implant exchange.

I am going to call him next week to see if he would talk to me a little further about the tissue matrix option. Your post and the feedback from other surgeons gave me the courage.


Sid Schwab said...

Christina, I'm glad you found the blog and that it's still helpful. It sounds like you're taking charge in a very positive way.


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...