Breast Reconstruction -- An Expert Interview With Robert T. Grant, MD

Pippa Wysong

Disclosures

December 28, 2009

Editor's note:

Breast reconstruction to repair deformities resulting from mastectomy or partial mastectomy is a viable and increasingly common procedure. Yet, there are still issues surrounding accessibility of breast reconstruction for many women. There are also differences in how the plastic surgeon should approach patients who are undergoing cancer treatment compared with women who are undergoing regular cosmetic procedures. Robert T. Grant, MD, is Plastic Surgeon-in-Chief at the New York-Presbyterian Hospital, as well as at the University Hospitals of both Columbia and Cornell. He spoke to Medscape's Pippa Wysong about issues concerning reconstructive surgery in patients with breast cancer.

Medscape: Let's begin with defining the differences between cosmetic surgery and reconstructive surgery of the breast.

Dr. Grant: Cosmetic surgery is surgery performed on a normal structure to change its appearance. Reconstruction surgery is surgery on a structure that has been damaged from an injury or as a treatment for another illness, or for a congenital reason.

Breast reconstruction started becoming popular in the 1980s. At that point, surgeons began using tissue-expander techniques -- a type of medical device similar to a collapsed balloon. These devices could be placed temporarily under the skin after mastectomy and then filled to provide a pocket for positioning of a subsequent implant. People also began performing "spare parts surgery," to make a breast out of excess tissue from the tummy or other areas.

Medscape: These are expensive operations. Are there problems with insurance coverage?

Dr. Grant: In the past, insurance companies often said that because this was cosmetic surgery, they wouldn't pay for it. They do now. Plastic surgeons did the first outcome studies to show that breast reconstruction was far more than just cosmetic surgery. The benefits in terms of quality of life and restoration of body image transcended anything in the cosmetic arena. The effects on patients are as powerful those seen in reconstruction for repair of deformities from accidents, injury, or for congenital reasons. Eventually, both state and federal legislation were passed mandating that, with certain exceptions, breast reconstruction must be covered by insurers.

Medscape: What are some of the accessibility issues?

Dr. Grant: In some areas of the country, the number of women who get breast reconstruction after mastectomy remains pitifully small, maybe 1 out of 5 eligible women. The good news is, insurance companies now consider it a covered expense. The bad news is insurance companies reimburse doctors so little for many of these procedures -- these payments don't begin to cover the hours of effort and specialized skills associated with the complex reconstruction and care that is required. This means that many plastic surgeons remain out of network for breast reconstruction, and many patients can't afford to go out of network to pay for them.

As a result, many patients find it difficult to find an in-network surgeon to care for them who offers them the full spectrum of breast reconstructive options.

That gets us into another topic. We ration care in the US in all sorts of ways that are not overt, but covert. This is one of them. Still, most plastic surgeons will do what they can for women with breast cancer because it's a focus of our national plastic surgery groups -- if someone needs access to breast reconstruction, we'll do everything we can to make sure the patient receives appropriate referrals and care.

Medscape: Are there geographic issues?

Dr. Grant: A maldistribution of plastic surgeons might exist, affecting rural areas, or patients in rural areas might be unable to find a qualified plastic surgeon nearby who can offer the full spectrum of breast reconstruction choices and perform them well.

Medscape: Regarding mastectomy vs partial mastectomy patients, how many undergo reconstruction?

Dr. Grant: Rates vary between more affluent areas and urban centers, and rural areas. Rates of reconstruction also vary by socioeconomic group. African-American patients, in particular, have lower rates of breast reconstruction than other groups. Studies show that they just don't have access to the same kind of healthcare that non-African-American women do. And because of that they tend to present with bigger tumors, which sometimes preclude or delay breast reconstruction. African Americans also tend to have a different constellation of underlying medical problems than non-African Americans: obesity, diabetes, asthma, pulmonary diseases, and so on. Doctors have to factor in all of these things when it comes to evaluating the patient's risk from having reconstruction.

Medscape: At what point in her treatment does a patient qualify for reconstructive surgery?

Dr. Grant: There is no one comprehensive answer to that question. We like to do as much reconstruction as we can at the time of the mastectomy because this can minimize subsequent hospitalizations. But not every patient is a good candidate to have the reconstructive process started at the time of mastectomy. If the patient is a good candidate -- if her tumor isn't too big, and there are no other major medical problems or extensive disease -- then yes, immediate reconstruction at the time of mastectomy can be performed. Of note, it spares the psychological trauma of having to wake up with no breast on the chest wall.

Medscape: What are the issues related to delayed reconstruction?

Dr. Grant: Some women choose to delay reconstruction until after chemotherapy or radiation. It is important to factor radiation into the reconstruction. Radiation is used more frequently in women with recurrent chest or armpit lymph node disease, but has effects on all tissues. Radiation can change the nature of the reconstruction results and increase the risk for complications in terms of wound healing; it can affect symmetry with the other side if the patient has an implant-based reconstruction, and radiation can affect the expected scar tissue that forms around every implant that is placed in reconstruction. Radiation treatment can increase the rate at which scar tissue squeezes tightly around the implant, a condition called capsular contracture. A harder or different shape to the implant can result.

Medscape: Sounds like the plastic surgeon needs to talk to the radiation therapist.

Dr. Grant: It is best if these patients are cared for by a team of professionals who get together to talk about the patient in a group. This is generally done at academic medical centers. You need this so the radiation therapist, the breast oncologic surgeon, plastic surgeon, [and] medical oncologist who provides the chemotherapy can all be on the same page in terms of what the patient can expect, what the treatment plan is, and how to individualize the treatment plan.

It's difficult for patients because these are not black-and-white decisions -- they're just professionals' best opinions. At the end of the day, we rely on patients to make the final decisions because they're the ones who have to live with the consequences of those decisions.

Organized support groups of other patients who have been through it all serve as an invaluable resource, too; they help empower patients to get the information and knowledge they need to make the right decisions. Academic medical center settings tend to have these support groups. In small-community rural hospitals, women may lack access to surgeons who know how to perform the full spectrum of reconstructive surgeries, as well as other resources, such as support groups or team approaches.

Medscape: Are there special concerns or risks related to reconstructive surgery with patients undergoing continuing cancer therapy?

Dr. Grant: Yes, but for most patients the risks are so small the benefit of having the breast reconstruction is worth it. When examining a patient who is scheduled for a mastectomy, or who has had a partial mastectomy and is a candidate for breast reconstruction, plastic surgeons help her figure out her specific risk-benefit ratio. The risks include possible infection, exposure or rejection of the implant, and risks from additional anesthesia time. If you use "spare parts" from other parts of the patient's body, there are risks related to scars and healing complications at the donor sites, a possible need for blood transfusions for longer operations, and so on.

Medscape: Any tips for how plastic surgeons can best work with the oncologic surgeon?

Dr. Grant: Plastic surgeons don't interfere with discussions between breast cancer oncologic surgeons and patients. We want all patients and caregivers to decide to do the best thing to improve each patient's survival. Depending on what choice they make in terms of whether it's a mastectomy or a partial mastectomy, there are many approaches to reconstruct the breast mound -- given the parameters that are established by the approach to treatment of the primary tumor.

I think most plastic surgeons who do this sort of work already work with breast oncologic surgeons. We in the United States have chosen a method of care that separates the team that treats the cancer from the team that reconstructs the breast. It's a different team of doctors who make the decisions on treating the cancer, and the doctors who reconstruct the breast are just basically dealing with the consequences of those treatment decisions. There are different approaches elsewhere in the world.

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