Should you delay your breast reconstruction?

WHY TIMING CAN MAKE A DIFFERENCE

The NhS performs around 23,000 mastectomies every year, but only 21 per cent of women have an immediate reconstruction. While some women won’t want it, there are concerns that the rate of immediate reconstruction is lower than it should be. Sometimes this may be down to cost — this type of surgery can cost up to £20,000.

According to Ruth Waters, a consultant plastic and reconstructive surgeon who specialises in breast surgery at the Queen elizabeth hospital in Birmingham, every woman diagnosed with breast cancer should be offered all the options. ‘Obviously some types of reconstructive surgery are better for certain patients. But every patient should at least have the chance to be offered what is now available.’

Reconstruction may be delayed until all other treatment, such as chemotherapy and radiotherapy, is completed.

IF YOU’RE HAVING CHEMOTHERAPY . . .

MANy breast units around the country offer patients chemotherapy or hormones prior to surgery to shrink the tumour. Depending on the aggressiveness of the cancer, ‘this can be very successful,’ says Geraldine Mitchell, a breast surgeon at the Royal Liverpool University hospital.

‘ Between 33 and 46 per cent of patients will respond to this to the extent that under the microscope we can no longer spot any cancer cells.

‘That doesn’t mean there will be no surgery — because there could be tiny satellite cancer cells remaining — but it does mean we can save those patients from a disfiguring operation or mastectomy.’

This may mean the patient may need a less extensive reconstruction operation.

‘The order of chemotherapy and surgery very much depends on the type of breast cancer being treated,’ explains Lester Barr, a breast cancer surgeon at the Genesis Breast Cancer Prevention Centre at Wythenshawe hospital in Manchester.

‘So for example with heR2positive breast cancer [which tests positive for a protein that promotes the growth of cancer] we like to give chemotherapy first, as it shrinks the tumour and makes the surgery easier.

‘And also the chemotherapy is the priority — we have drugs such as herceptin which work effectively in treating this cancer because they specifically target the heR2 molecule.

‘ So we like to get the chemotherapy in early.’

With triple negative breast cancer, chemotherapy is also suggested before any surgery, he says.

But with women with certain types of oestrogen receptor positive breast cancers, it’s more usual to wait until after the surgery to decide if chemotherapy is needed, explains Dr Sacha howell, a consultant in medical oncology at the Christie and Wythenshawe hospitals in Manchester.

‘It’s important to look at the biology of the tumour. If it’s a small tumour, less than 2 cm in size, chemotherapy may not be needed unless it is an especially aggressive cancer or if it has spread to the lymph nodes.’

If chemotherapy does take place first, it can take up to a couple of months after treatment has finished for a woman to be well enough to go ahead with surgery, adds Mr Barr.

‘By then haemoglobin levels — needed for red blood cells — will have recovered and white cells, needed to fight infection, are functioning well.’ Of course, the order of treatment is ultimately the patient’s decision — some will want to have reconstruction first to get all their surgery ‘out of the way’.

‘It’s important to remember that if you do a simultaneous immediate reconstruction as part of a mastectomy operation there’s a chance chemotherapy will be delayed because you are making a recovery from quite a big operation,’ says Mr Barr.

‘ It’s one of the reasons, if chemotherapy is strongly advised, to have it first.’

If the chemotherapy is to be given after the surgery, the timing depends on the procedure.

Recovery of about four weeks is needed after a mastectomy before chemotherapy can begin.

The same is true if the operation also includes implant surgery. For more extensive reconstructive surgery using the patient’s own tissue, recovery before chemotherapy can take between four to ten weeks.

IF YOU’RE HAVING RADIOTHERAPY . . .

IF RADIOTheRAPy is needed, different factors have to be taken into account for reconstructive surgery.

The treatment can mean the surrounding tissue on the breast won’t heal well, says Dr howell. ‘If you have had radiotherapy prior to reconstruction, it limits the wound healing ability.’

Reconstruction is possible before radiotherapy, but the treatment may spoil the cosmetic outcome, as radiotherapy can change the shape or size of the reconstructed breast, explains Mr Barr. ( See reconstruction options, on the previous page.)

‘The job of the team is to calculate the risk of local recurrence and long-term survival when deciding treatment options,’ adds Dr howell.

‘This should be discussed very early after diagnosis. It’s vital patients know all the facts and understand the issues and options open to them.’