October is breast cancer awareness month, so I thought I’d dedicate a post on everything I know about breast cancer. It’s a massive topic so I’ll try my best to be concise and easy to understand. Since 2013, I have worked on Plastic & Reconstructive surgery units across Melbourne, Canberra and Sydney where I’ve looked after hundreds of women with breast cancer who have had their breast(s) reconstructed after they’ve had their breast removed (mastectomy). I’ve also personally known women who have gone through breast cancer. Reconstruction should be offered to every woman who has had a mastectomy, but unfortunately it’s not part of the conversation in many parts of the world.
Background
Breast cancer is the commonest cancer amongst women worldwide. It’s important for women to check their breasts monthly for lumps, and ideally it should be around the same time each month, as breasts change with the menstrual cycle. Here’s a video on how you can do a breast self-exam. By being breast-aware (knowing how your breast feels like), it is easier for you to detect any changes if and when they occur. Women aged 50-74 in Australia are offered a free mammogram every 2 years as part of the national breast screening program. Women who have a strong family history can also start getting mammograms from age 40.
If there is a change detected in your breast(s), you should see your GP. The diagnosis of breast cancer is by a triple test; 1) a clinical examination by the GP, 2) imaging and 3) biopsy. Sometimes a mammogram isn’t adequate (for example if you have a dense breast), so an ultrasound or MRI may be ordered to see the lump better. The biopsy gives more information about the type of breast lump it is. If it is cancer, it can tell us what type of breast cancer and how aggressive the cancer might be. Cancer cells have receptors on them – they are tested for oestrogen, progesterone and herceptin receptors. This can give an idea of prognosis, as well as guide further treatment. Oestrogen positive and herceptin negative breast cancers tend to confer a better prognosis.
Treatment
Once breast cancer is diagnosed, the first step is surgery to remove the cancer. Depending on the size and type of breast cancer, the whole breast may need to be removed (mastectomy), or just the lump (lumpectomy). Often at the same time of surgery, the lymph nodes are assessed. The lymph nodes in the armpit are the first place the breast cancer will spread (see image below). A sentinel lymph node biopsy is removing the first lymph node(s) the breast tissue drains to. If it is negative, it is unlikely that the breast cancer has spread beyond the breast. If it is positive, further treatment would be needed. The specimen from the surgery is sent to the lab for further testing to confirm the diagnosis and look at finer details of the cancer.
Depending on the type of cancer and if it has spread, other treatment modalities are chemotherapy (including hormone therapy) and radiotherapy.
Reconstruction
There is a significant psychological impact on the woman who undergoes a mastectomy that is unique and different to other types of cancer. The breasts are an important part of identity and feeling feminine, so the loss of a breast (or both breasts), can affect the woman’s sense of self. Having reconstruction at the same time as the mastectomy means that she can have the one surgery for both the cancer removal and reconstruction, rather than needing a second procedure later down the track. It also has psychosocial benefits – she can have a reconstructed breast straight away rather than living with just one breast (or none, if both breasts were affected by cancer). However, sometimes it’s not possible for immediate reconstruction. The decision to have immediate or delayed reconstruction is a complex one, and there is no international consensus or decision tree.
The type and timing of reconstruction depends on a number of factors – whether the woman requires chemo- and/or radio-therapy, the type of breast cancer, patient choice, patient body size and shape, and patient co-morbidities (like smoking, obesity and diabetes). There are two broad categories of reconstruction; autologous (which is using the patient’s own tissues), and implant-based.
For autologous reconstruction, the patient must have healthy tissues. If the patient is a heavy smoker, obese, or diabetic, this can result in a poor surgical outcome so autologous reconstruction may not be possible. There are a few options for autologous reconstruction – abdominal flaps are the popular choice. The lower abdominal skin and fat is removed and moved up to the breast. (The added benefit of this is a tummy tuck!) However, if the woman is too lean, she may not have enough fat for this procedure. The other option to reconstruct the breast is using a muscle from the back called the latissimus dorsi (the ‘lats’ for all you gym goers). Some of these operations take a very long time, so the patient must be fit for prolonged surgery.
For implant-based reconstruction, a breast implant or a tissue-expander is used. A tissue expander is a balloon that sits under the skin and is gradually filled up over several weeks so that the skin doesn’t contract. This preserves the skin for placing an implant or autologous reconstruction later. The reason for doing this is that sometimes women need adjuvant chemo- or radio-therapy, which can affect the way skin heals after surgery. In particular, radiotherapy can cause scarring and hardening of the skin, and can make the reconstructed breast shrink and deform. So, the reconstruction is delayed until the radiotherapy is completed.
When a woman goes to see a breast surgeon about cancer surgery, reconstructive options should be a part of the conversation. Having a diagnosis of cancer can be overwhelming and emotional, and there’s so much information to take in. However, going through reconstruction is often a helpful part of the recovery as it makes you feel more “normal” than you otherwise would without a breast. If you have been diagnosed with breast cancer and go to see a surgeon, do make sure that reconstruction is part of your discussion along with all the other questions you will no doubt have about the journey you are about to go on.
That’s breast cancer and reconstructive surgery in a nutshell. I hope this was informative and might help someone who has been diagnosed with breast cancer, or knows someone who has. I might not know everything, but if you have any further questions I’ll try and answer them or guide you to more information.
Take care,
Miko xx
