Breast reconstructive surgery: Providing options for women

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This is a story about four women who faced breast cancer and emerged stronger in spirit and wiser from experience. For each woman, undergoing a mastectomy became part of the journey to a new beginning.

While Josie Bespolko chose to have a mastectomy to prevent the spread of early stage breast cancer, Judy Porter, Cindy Cwiertniewski and Maria Eisenring, each decided to undergo a double mastectomy to reduce their risk of developing breast cancer due to inherited gene mutations. But the journey to wellness does not have to end after a mastectomy. In fact, for Josie, Judy, Cindy and Maria, it was just the turning point.

For many women who face the prospect of losing their breast(s) due to cancer, breast reconstructive surgery is an option. The goal of breast reconstruction is to provide symmetry so patients are reminded less of their cancer diagnosis. In breast reconstruction a soft supple mound is created using either implants or autologous tissue (the patient’s own tissue). A reconstructed nipple and areola can also be included. The timing for breast reconstruction can be immediate (at the same time as mastectomy), early (three to four months following mastectomy) or late (three months or more after mastectomy).

What is essential for women in deciding if breast reconstruction is right for them is information and expert guidance from health-care professionals. At the Juravinski Cancer Centre (JCC), surgeons including Dr. Nicole Hodgson, Surgical Oncologist and Dr. Arianna Dal Cin, Head of Service in Plastic Surgery, work together to provide patients with comprehensive and complete breast cancer care.

As part of the JCC’s multidisciplinary approach to cancer care, breast cancer patients meet with their surgeon when exploring surgical treatment plans, and if candidates, they are then referred to Dr. Dal Cin to discuss breast reconstruction options. The involvement of both physicians in care planning is essential in helping patients make informed decisions.

For Cindy Cwiertniewski, who found out through genetic testing that she was a carrier of the BRCA 1 gene mutation and had up to an 80 per cent risk of developing breast cancer in her lifetime (the average woman has an 11 per cent risk), speaking with Dr. Hodgson and Dr. Dal Cin helped her decide to undergo a double skin sparing mastectomy and immediate breast reconstruction with TRAM (transverse rectus abdominis muscle) flap reconstruction – a procedure which uses tissue and muscle from the lower abdominal wall to create the breast mound. Although the physical changes from both procedures may be overwhelming for many women, Cindy says both doctors helped her choose her care route.

“Dr. Hodgson and Dr. Dal Cin enabled me to make an informed decision because they cared about me. From the initial explanations of breast cancer and my options to preparing me for surgery, they made sure I understood all the facts so there were no surprises along the way,” says Cindy.

Inside the operating room, Dr. Hodgson and Dr. Dal Cin work together to make a positive difference for their patients. This was certainly true for 33-year-old breast cancer survivor, Maria Eisenring, who underwent a double skin sparing mastectomy and immediate reconstruction with final silicone implants (tissue expansion was not required in this case). In this highly coordinated procedure, both surgeons are in the operating room at the same time – after Dr. Hodgson completes a mastectomy on one breast, Dr. Dal Cin begins the reconstruction process. Although not every patient is a candidate, for those who are, it can help make the experience more positive. “I was extremely lucky. I went into surgery with two breasts and came out with two breasts,” says Maria. “Mentally, this was a huge deal and I’m grateful to both doctors for what they have done for me.”

The experience can also be positive for patients who undergo delayed breast reconstruction. Josie Bespolko, 51, was advised by her physician to delay breast reconstruction after a mastectomy. In the interim, Josie wore a prosthesis but was anxious to move ahead with the final surgery. After meeting with Dr. Dal Cin to discuss her options, Josie made the choice to go with TRAM flap reconstruction. In September 2007, two years after her initial diagnosis Josie underwent breast reconstructive surgery. She emerged from the procedure feeling like she had been given a second chance. “I couldn’t believe how I felt after the operation,” recalls Josie. “I felt whole again, I felt renewed and I looked good. I felt sexy for the first time in two years.”

Judy Porter, a 45-year-old cancer survivor who carries the BRCA 1 gene mutation was also happy with her outcome after recently going through exchange surgery to complete the breast reconstruction process. A tissue expander was used as part of skin sparing surgery when Judy underwent a double mastectomy. Since then, Judy has regularly visited Dr. Dal Cin for saline injections in order to stretch her skin in preparation for the final implants. Despite the long process, Judy is just glad she has chosen a route that will help reduce her chances of getting breast cancer. Her advice to other women going through a similar experience is to focus on the positive and to know and understand all their options. “Knowledge and information is key to making a decision that is right for you,” says Judy.

Ultimately, the decision for breast reconstruction rests on the type and stage of breast cancer, the patient’s overall well being, as well as the individual’s choice. Dr. Hodgson understands these decisions are personal but wants women to have enough information and resources to make informed decisions. “Moving forward, a lot more can be done to support women in their decision making process. A coordinated support system involving social workers and psychologists would be of value to women in helping them understand reconstruction outcomes,” explains Dr. Hodgson.

In keeping with this, a new breast reconstruction clinic is being established at the JCC. The clinic will be available to mastectomy patients who are candidates for breast reconstruction. The main purpose of the clinic will be to provide patients with options on breast reconstruction, but Dr. Dal Cin is quick to point out that the overall wellbeing of the patient is the priority in all care decisions being considered.

“Foremost, our objective is to provide patients with the most effective treatment for cancer. And among patients who are candidates, our goal is not to have a 100 per cent rate of reconstruction, but to provide them with information to make a choice that is right for them,” says Dr. Dal Cin.