Reconstruction After Breast Cancer Surgery

Breast cancer forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and/or lobules (glands that make milk).

It existence was acknowledged thousands of years ago. The ancient Egyptians in 1600BC described it as a “coagulum of black bile” within the breast and thought that getting rid of the excess bile¬ — through surgery, special diets, purging or even attaching leeches to draw out the bad blood— could cure the disease. In 1889, American surgeon William Halsted, a founder of renowned Baltimore teaching hospital Johns Hopkins, performed the first radical mastectomy removing the breast and underlying chest muscle in an attempt to cure the disease. It was not until the introduction of breast implants in 1963 that any reasonable breast reconstruction could be performed.

October was breast cancer treatment awareness month and currently the United States has the world’s highest breast cancer survival rate. Americans have a nine percent higher breast cancer survival rate than Canadians, 9 percent higher breast cancer survival rates than Germany and 15 percent higher than England. Aside from non-melanoma skin cancer, breast cancer is the most common cancer among women in the United States. It is also one of the leading causes of cancer death among women of all races and Hispanic origin populations. However, breast cancer death rates have been declining since the early 1990s for all women in the US except American Indians/Alaska Natives, among whom rates have remained stable due to screening and early diagnosis.

It is a disease that effects rich and poor. Celebrities like Sheryl Crow, Christina Applegate and Sharon Osbourne have had breast cancer surgery. The surgery involves

• removing the part of the breast containing the cancer, 
• removing all of the breast containing the cancer (mastectomy) or 
• removing the breast in a women at high risk for developing a breast cancer (prophylactic mastectomy). 

It is followed in many cases by chemotherapy and/or radiation therapy. Some surgeons will spare the nipple in certain cases. Once removed the plastic surgeon is called upon to make a new breast i.e. reconstruct the breast and if necessary the nipple. Reconstruction can be “immediate,” performed at the same time as the mastectomy, or “delayed,” performed in a separate surgery later. From the late 1990s to the late 2000s, the rate of immediate reconstruction after mastectomy increased from about 21% to 38%--an average increase of 5% per year. The field of breast reconstruction has made major advances over the last 25 years. The reconstruction can involve

• a breast implant or
• use the patient's own tissue i.e. fat from elsewhere on the body (abdomen, hips, buttocks or thighs) or
• a combination of the patient's own tissues and a breast implant.

Breast reconstruction is currently very different than it was in 1963 when breast implants were first introduced and currently include:

Tissue expander reconstruction with later replacement of expander with an implant.

Latissimus dorsi (LD) muscle from the back moved to the front with or without an implant.

TRAM flap moving lower abdominal skin and fat to the chest

Free flap reconstructions where skin and fat from the lower abdomen or elsewhere on the body is moved to the chest and the blood vessels attached in their new location.

From the late 1990s to the late 2000s, the rate of immediate reconstruction after mastectomy increased from about 21% to 38%. During this period, the number of reconstructions using the patient's own tissues remained relatively unchanged but the rate of reconstructions using implants increased by an average of 11% per year. Before that TRAM flap reconstructions were the most popular means of reconstruction. Part of the reason for this was more patient's were having both breasts removed and did not have enough of their own tissues to make 2 new breasts. Also patients with non-private health insurance (Medicare) are more likely to have implant reconstructions and over time the percentage of patients on Medicare is going up.

The overall complication rates are similar for the 3 common types of flaps used during breast reconstruction, but the types of complication, resource use, and costs differ. Looking at patients who received free flap, latissimus dorsi (LD) flap with implant or expander, or transverse rectus abdominus myocutaneous (TRAM) flap breast reconstruction during the first 6 months of 2008 it was noted that TRAM flap reconstructions were associated with the highest return rates for the treatment of complications, LD flap reconstructions were associated with the highest return rates for procedures that were not related to complications, and free flap reconstructions were associated with the highest total costs within the first 18 months after surgery. The rates of diabetes, smoking, and obesity were the same in each group of patients. Complications related to the implant, graft, or mesh were higher with the LD flap (19%) than with the free flap (11%) or the TRAM flap (10%) (P = .004). Hematomas and seromas were more frequent with the LD flap (6%) and TRAM flap (5%) than with the free flap (2%) (P = .04). Skin/fat necrosis was more frequent with the free flap (8%) and TRAM flap (6%) than with the LD flap (2%) (P = .006). Wound problems were more frequent with TRAM flap (6%) than with free flap (3%) or LD flap (1%) (P = .01). Consequently the LD flap patients had the highest surgical revision rate and the TRAM flap patients had the highest complication rates requiring return to the operating room.

The average cost of breast reconstruction was $40,079 per patient. The cost for free flaps was $56,205, for TRAM flaps was $33,380, and for LD flaps with implant/expander was $30,783.

Looking at the average cost per patient for specific complications, the highest was for the treatment of infection with a TRAM flap ($2529), followed by the treatment of an implant-related complication with an LD flap ($2145).

In the early 1990s health insurance companies began denying coverage for breast reconstruction surgery citing that the cancer was medically necessary but the reconstruction was not. It took an act of congress passed in October 1998 (Womens' Health and Cancer Rights Act) requiring group health plans and health issuers that provide medical and surgical benefits with respect to medically necessary mastectomy for breast cancer, to cover the cost of reconstructive breast surgery for women who have undergone a mastectomy. The law states:

• The attending physician and patient are to be consulted in determining the appropriate type of surgery.
• Coverage must include all stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the opposite breast and the cost of prostheses and complications of mastectomy, including lymphedema.

This law should ensure that the insurance companies will not be able to force patients to choose reconstructions just because they are cheaper. Despite this 70% of women eligible for reconstructive surgery after mastectomy in the US are not fully informed of their reconstructive options. Women who get reconstruction are more likely to go back into the work force, are less likely to be reclusive and more likely to go back out and do what they used to do.

Breast Cancer Statistics US

• Estimated new cases and deaths from breast cancer in the United States in 2012: New cases: 226,870 (female); 2,190 (male) Deaths: 39,510 (female); 410 (male) About 1 in 8 U.S. women (just under 12%) will develop invasive breast cancer over the course of her lifetime.
• In 2011, an estimated 230,480 new cases of invasive breast cancer were expected to be diagnosed in women in the U.S., along with 57,650 new cases of non-invasive (in situ) breast cancer.
• About 2,140 new cases of invasive breast cancer were expected to be diagnosed in men in 2011. A man’s lifetime risk of breast cancer is about 1 in 1,000.
• From 1999 to 2005, breast cancer incidence rates in the U.S. decreased by about 2% per year. The decrease was seen only in women aged 50 and older. One theory is that this decrease was partially due to the reduced use of hormone replacement therapy (HRT) by women after the results of a large study called the Women’s Health Initiative were published in 2002. These results suggested a connection between HRT and increased breast cancer risk.
• About 39,520 women in the U.S. were expected to die in 2011 from breast cancer, though death rates have been decreasing since 1990 — especially in women under 50. These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness.
• For women in the U.S., breast cancer death rates are higher than those for any other cancer, besides lung cancer.
• Besides skin cancer, breast cancer is the most commonly diagnosed cancer among American women. Just under 30% of cancers in women are breast cancers.
• White women are slightly more likely to develop breast cancer than African-American women. However, in women under 45, breast cancer is more common in African-American women than white women. Overall, African-American women are more llkely to die of breast cancer. Asian, Hispanic, and Native-American women have a lower risk of developing and dying from breast cancer.
• In 2011, there were more than 2.6 million breast cancer survivors in the US.
• A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 15% of women who get breast cancer have a family member diagnosed with it.
• About 5-10% of breast cancers can be linked to gene mutations (abnormal changes) inherited from one’s mother or father. Mutations of the BRCA1 and BRCA2 genes are the most common. Women with these mutations have up to an 80% risk of developing breast cancer during their lifetime, and they are more likely to be diagnosed at a younger age (before menopause). An increased ovarian cancer risk is also associated with these genetic mutations.
• In men, about 1 in 10 breast cancers are believed to be due to BRCA2 mutations, and even fewer cases to BRCA1 mutations.
• About 85% of breast cancers occur in women who have no family history of breast cancer. These occur due to genetic mutations that happen as a result of the aging process and life in general, rather than inherited mutations.
• The most significant risk factors for breast cancer are gender (being a woman) and age (growing older).
• As of Jan. 1, 2009, there were about 2,747,459 women alive in the United States with a history of breast cancer. This includes women being treated and women who are disease-free.

Breast Cancer Statistics Canada

• Breast cancer is the most common cancer affecting women in Canada.
• One in nine women is expected to develop the disease during her lifetime, according to the Canadian Cancer Society. Last year, 23,400 women were diagnosed in Canada.
• But fewer women are dying from the disease, likely due to increased screening and improvements in treatment. The current five-year survival rate in Canada is 88 per cent.
• The mortality rate is the lowest it has been since 1950, according to the cancer society.
• In 2010-’11, a total of 24,735 women had mastectomies in Canada, according to the Canadian Institute for Health Information. Of those, just 945 women — about one in 26 — had immediate reconstruction. Only 1,719 women — about one in 15 — had delayed reconstruction. In 2006, fewer than 10 per cent of Canadian women who had mastectomies also had reconstruction.

The Belinda Stronach Chair in Breast Cancer Reconstructive Surgery was created at Toronto General Hospital in November 2007. However as of 2012 no one has been appointed to the position. The delay is due to lack of funding in that after 5 years only half of the required money had been raised. However some of the funds have gone towards research, training fellowships for surgeons and patient education. Few surgeons in Canada do the more extensive procedures because of poor reimbursement.

Breast Cancer Statistics UK
In 2009 21% of mastectomy patients underwent immediate breast reconstruction.

See the online booklet What You Need To Know About™ Breast Cancer to learn about breast cancer types, staging, treatment, and questions to ask the doctor.

Aaron Stone MD - Plastic Surgeon Los Angeles
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