Some Hidden Choices in Breast Reconstruction

By NATASHA SINGER

24 dec 2008--For many cancer patients undergoing mastectomies, reconstructive breast surgery can seem like a first step to reclaiming their bodies.

But even as promising new operations are gaining traction at academic medical centers, plastic surgeons often fail to tell patients about them. One reason is that not all surgeons have trained to perform the latest procedures. Another reason is money: some complex surgeries are less profitable for doctors and hospitals, so they have less of an incentive to offer them, doctors say.

“It is clear that many reconstruction patients are not being given the full picture of their options,” said Diana Zuckerman, the president of the National Research Center for Women and Families, a nonprofit group in Washington.

One patient, Felicia Hodges, a 41-year-old magazine publisher in Newburgh, N.Y., chose a double mastectomy after she was found to have cancer of the right breast in 2004. She consulted a plastic surgeon, who offered her only reconstruction with breast implants, she said.

Ms. Hodges chose implants filled with saline, a procedure for which more than a third of reconstruction patients underwent a follow-up operation, studies show.

Ms. Hodges developed wound-healing problems that required her surgeon to remove her right implant, and she was left with a concave chest with a quarter-size hole in it, she said; she described the experience as “worse than the mastectomy.”

Then Ms. Hodges discovered a chat room on the patient-information Web site breastcancer.org, where women share detailed information about breast reconstruction beyond what they may have heard from their doctors.

Ms. Hodges learned of newer, more complex procedures that involve transplanting a wedge of fat and blood vessels from the abdomen or buttocks, which would be refashioned to form new breasts.

“It’s unfortunate that a lot of general surgeons, breast surgeons and plastic surgeons don’t mention it,” said Ms. Hodges, who underwent one of the surgeries, known as a GAP flap, last year. A lifelong athlete and a karate enthusiast, she is now back at her dojo.

To raise awareness of breast reconstruction and to market it to patients, the American Society of Plastic Surgeons has adopted the vocabulary of the movement to support a woman’s freedom to choose an abortion, adjusting it for women with breast cancer. Although women “don’t choose their diagnosis, they can choose to go ahead with reconstruction or not, and with the aid of a knowledgeable plastic surgeon they can choose what their options might be,” Dr. Linda G. Phillips, a plastic surgeon in Galveston, Tex., said in a telephone news conference organized by the plastic surgery society to mark Breast Cancer Awareness Month in October. “Then they have that much more power over their lives if they have that power to choose.”

But for many patients, the options may be limited because their doctors are not proficient in the latest procedures. Dr. Michael F. McGuire, the president-elect of the American Society of Plastic Surgeons, said it is not unusual for surgeons to omit telling patients about operations they do not perform. He compared the rise of more complex breast reconstruction to the advent in the late 1980s of minimally invasive laparoscopic surgery of the gallbladder.

“At the time, only a small percentage of surgeons were doing them and doing them well,” said Dr. McGuire, who is chief of plastic surgery at St. Johns Hospital in Santa Monica, Calif. “If you were not familiar with laparoscopic gallbladder surgery, you were still doing it the traditional way with an open great big scar across the abdomen.”

Uneven information about reconstructive options is a subset of a larger problem, said Dr. Amy K. Alderman, an assistant professor of plastic surgery at the University of Michigan Medical School in Ann Arbor. Only one third of women undergoing operations for breast cancer said their general surgeons had discussed reconstruction at all, according to a study by Dr. Alderman of 1,844 women in Los Angeles and Detroit that was published in February in the journal Cancer.

“In the big picture, it would be great if we could just get doctors to tell people they have an option of reconstruction,” Dr. Alderman said.

Once patients are so informed, she added, plastic surgeons should tell them of options beyond implants. “The next hurdle would be letting them know that using their own tissue is an option, because my guess is that they are not even getting that far in the discussion,” Dr. Alderman said.

About 66,000 women in the United States had mastectomies in 2006, the latest figures available, according to the federal government. And about 57,000 women had reconstructive breast surgery last year, according to estimates from the plastic surgery society.

For many of these women, the operations were more about feeling whole again than about restoring their appearance.

Implant surgery is the most popular reconstruction method in the United States. Often performed immediately after a mastectomy, it initially involves the least surgery — usually a short procedure to insert a temporary balloonlike device called an expander — and the shortest recovery time.

But implants come with the likelihood of future operations. Within four years of implant reconstruction, more than one third of reconstruction patients in clinical studies had undergone a second operation, primarily to fix problems like ruptures and infections, and a few for cosmetic reasons, according to studies submitted by implant makers to the Food and Drug Administration. (Reconstructive patients are more likely to develop complications after implant surgery than cosmetic patients with healthy breast tissue.)

Complication rates for newer flap procedures like the one Ms. Hodges had have not been well studied, though many surgeons say they are less likely to require follow-up operations. The most common flap procedure, named a TRAM flap, for the rectus abdominis muscle, cuts away a portion of abdominal fat, as well as underlying muscle containing blood vessels, and uses the tissue to rebuild a breast. The vessels provide a blood supply for the new breast mound. The procedure promises a more lifelike look and feel, but it carries a risk of a weaker abdominal wall and hernia.

Another flap method, the DIEP free flap, is the newest and most intricate, named for the abdomen’s deep inferior epigastric perforator vessels. It involves moving abdominal fat and blood vessels, but no muscle. The DIEP flap theoretically holds out the promise of a reduced likelihood of abdominal problems. But Dr. Alderman cautioned that researchers have not yet conducted rigorous national studies that would establish a complication rate. Sometimes the flaps fail and need to be surgically removed.

All breast reconstructions involve a tradeoff, said Dr. Scott L. Spear, the chief of plastic surgery at Georgetown University Hospital in Washington. “The implants have a lower investment in the short term and a longer-term higher risk of having to redo it,” said Dr. Spear, who is a paid consultant to the implant maker Allergan. “The flaps have a bigger investment in the short run, but you are less likely to revise it in the long run.”

Dr. Spear said plastic surgeons sometimes fail to mention the flap options for the simple reason that implant surgery can be more profitable. “It’s really embarrassing to say so, but, from a purely selfish point of view, if you are looking at insurance reimbursement for TRAM and DIEP flaps, it’s a loss leader,” Dr. Spear said. “They really require so much time and effort that a surgeon thinks, ‘Man, I can’t afford to do this.’ ”

Nevertheless, Georgetown, long a center of expertise for implant reconstruction, recently hired a plastic surgeon who specializes in the more complicated tissue flaps.

A typical surgeon in Manhattan charges insurers about $7,000 for a one-hour implant reconstruction, but for a DIEP procedure that takes 6 to 12 hours, the going rate is $15,500.

Although health insurers are required by federal law to cover reconstructive breast surgery after mastectomies, the government does not set private insurance rates. Flap reconstruction typically requires a higher out-of-pocket co-payment than implant surgery.

“In certain geographical areas where it is badly reimbursed, it’s a disincentive for plastic surgeons even to do the work,” said Dr. Richard A. D’Amico, a past president of the American Society of Plastic Surgeons, speaking of the flap procedures.

Dr. Stephen R. Colen, the chairman of plastic surgery at Hackensack University Medical Center in New Jersey, said plastic surgeons might also not inform patients about the flap procedures because they lacked the advanced training in microvascular surgery needed to perform them.

“A lot of patients are offered implants because the surgeon does not know how to do the flap, and then the implant fails and they need the flap anyway,” Dr. Colen said.

To counter doctors who might routinely steer patients to implants, Dr. Colen started a program at his hospital in which women can meet directly with an impartial physician’s assistant, who goes over the benefits and drawbacks of reconstruction methods.

“We sort of wanted to take the flow of the patient out of the control of the physician and put it in the hands of a medical person who has no personal or financial interest,” Dr. Colen said.

Dotti Campbell, a retired nurse in Crossville, Tenn., said the plastic surgeon who performed her breast reconstruction after a mastectomy offered her only an implant. “That was his procedure,” said Ms. Campbell. Her first implant developed hardened scar tissue and required replacement. Her replacement implant ruptured. Now she is going to have an operation to replace the second implant, she said.

The DIEP flap was developed by Dr. Robert J. Allen, a plastic surgeon in New York, New Orleans and Charleston, S.C., in 1992. Now surgeons at hospitals including the University of Pennsylvania Health System in Philadelphia and Beth Israel Deaconess Medical Center in Boston specialize in the procedure.

Dr. Allen and Dr. Joshua L. Levine, who operate together in Manhattan, often recommend a prospective patient talk at length with patients of theirs who have had a successful flap procedure, like Ms. Hodges, the magazine publisher and karate student, as well as with those whose first flap reconstructions failed and required a second procedure.

“Patients should not necessarily accept the first thing they hear as the end-all, because that is not necessarily the full story,” Dr. Allen said.