As recommendations for the treatment of breast cancer continue to evolve, techniques in breast reconstruction adapt to provide patients with the optimal outcomes for quality and safety. As a practice, we work closely with our breast surgery colleagues to understand the changes in the treatment of breast cancer so we may provide appropriate reconstructive options to our patients.
Two recent recommendations for the treatment of breast of cancer relate to reconstructive options that we often present to our patients. First, the American Society of Breast Surgery has released a position statement on July 28th, 2016 that has recommended against contralateral prophylactic mastectomy (CPM) for average-risk women with unilateral breast cancer. The statement was published in the Annals of Surgical Oncology. The American Society of Breast Surgery encourages an evidence-based approach to determine the value of contralateral prophylactic mastectomy in breast cancer patients. As per their statement, although contralateral prophylactic mastectomy may be appropriate for certain high-risk groups, research reveals that the majority of women with breast cancer obtain no oncologic benefit from the removal of a healthy breast. The society does recognize that patient preferences and values are an important part of the shared decision-making process.
How does this recommendation affect a patient’s options for reconstruction? The literature findings that contralateral prophylactic mastectomy does not reduce the overall survival in average-risk women suggests fewer bilateral mastectomy operations may be performed in the future. From a reconstructive standpoint, the same options for reconstruction exist for patients. Often times, unilateral implant reconstruction may give an unfavorable outcome after mastectomy when trying to match the native breasts. Even if a breast lift (mastopexy) is performed on the native, non-cancer breast, it is difficult to match the characteristics of an implant after mastectomy and reconstruction.
At Midwest Breast & Aesthetic Surgery in Ohio, we find that patients with unilateral mastectomy, are best suited for an autologous reconstruction (with their own tissue). Options such as DIEP flap or GAP flap are our mainstay reconstructive procedures for these types of patients. In reconstructing the breasts with a patient’s own tissue, we are able to closely match the contralateral breast. While in the operating room, we will actually weigh the mastectomy specimen, so that we may provide a one-to-one match of tissue volume to ultimately best create symmetry to the contralateral side. It should be noted that autologous reconstruction is not the most appropriate option for all patients. In some patients, particularly those with small cup size breasts, performing a unilateral reconstruction with an implant may work quite well. In these patients, we may discuss placing a small implant at the native breast to optimize the symmetry between the two sides.
The second recent development has been a recommendation from the Society of Surgical Oncology which has issued a consensus guideline for Physicians treating women who have ductal carcinoma in situ treated with breast-conserving surgery and whole breast irradiation. The recommendations relied on a review that examined the relationship between margin width and cancer recurrence in the breast that included 37 studies involving 7883 patients. The panel concluded “the use of a 2-millimeter margin as a standard for an adequate margin in DCIS treated with whole breast radiation therapy is associated with low rates of recurrence of cancer in the breast and has the potential to decrease re-excision rates, improved cosmetic outcome, and decrease health care costs. Clinical judgment should be used in determining the need for further surgery in patients with negative margins less than 2 millimeters.” Margins more widely cleared than 2 millimeters do not reduce the rate of recurrence of cancer in the breast and the routine use is not supported by evidence.
These are important changes in our understanding of the surgical management of breast cancer. Such a recommendation is in line with a more ‘minimally invasive’ approach to the treatment of breast carcinoma. With regard to the recommendations on 2 mm margin excision, we are seeing an increase in the number of “oncoplastic” type reconstructions that we do in coordination with our Surgical Oncology colleagues. In doing this type of reconstruction, as plastic surgeons, we essentially perform a breast tissue rearrangement using breast reduction techniques to re-establish the architecture of the breast and to allow for filling of the lumpectomy defect. As such, we can replace the area of the defect. Without reconstruction, the lumpectomy defect can become accentuated and correction can be challenging particularly after the patient has completed whole breast radiation treatment. We will often perform an oncoplastic breast reduction and leave the breast slightly larger than desired in order to account for changes in radiation treatment that frequently lead to loss of volume and skin elasticity over time. Once the affected breast has healed after radiation treatment, we will then perform an outpatient procedure to lift and reduce the other breast in order to create symmetry. On occasion, we will perform the bilateral reduction operation at the time of the lumpectomy.
As the surgical care of breast cancer continues to evolve, reconstructive techniques can be used to provide patients with optimal long-term aesthetic outcomes while remaining in line with the patient’s overall treatment plan.
For additional information or if you have any related questions, please contact us at 855-687-6227.