I was 29 years old when my gray-haired surgeon looked at me from across his desk and said, “I’d recommend a mastectomy.” My dad, seated to my left, exhaled hard. To my right, my mom sat in silence. Family history had repeated itself: My grandmother underwent a mastectomy at age 39. Now it would be me. But in the four days since my diagnosis, I had researched and stumbled upon a choice my grandmother never had.
“It’s OK,” I said to my dad. “They can rebuild me.”
They did. In one nine-hour procedure, a cancer surgeon performed a skin-sparing mastectomy, removing the nipple and tissue inside my right breast but leaving most of the skin intact. Then a plastic surgeon performed a free-flap reconstruction, extracting a portion of my stomach skin and fat and microscopically reconnecting it to my chest. Later, he reconstructed the nipple. The result was a breast that looks and feels like…my breast.
In the 14 years since, my reconstructed chest has seen me through highs and lows: confident in an evening gown while reporting from the Oscars as a TV correspondent; sorrowful, at times, when standing naked under bright bathroom lights, the faint scars tracing my areola reminders of invading disease and scalpels. Yearly screenings send my heart pounding, but my surgery has helped me be hopeful about the future.
Of course, some women don’t want any kind of reconstruction, sometimes due to health reasons or as a matter of preference. But women who do choose it report significant, lasting psychological benefits, in a way that transcends physical beauty, according to a study by Amy K. Alderman, M.D., assistant professor of plastic surgery at the University of Michigan Medical School in Ann Arbor. “Women tell me they feel whole again and more able to put cancer behind them,” she explains.
Which is why I’m alarmed that many women don’t know that options like the one I selected exist. Nearly 70 percent of women eligible for reconstruction aren’t informed of their reconstructive options, according to a 2007 study by Dr. Alderman. Almost 65 percent of general surgeons said they believe patients lack interest in reconstruction, and less than one in four consistently refers breast cancer patients to plastic surgeons.
Meanwhile, plastic surgeons often limit the time they devote to cancer patients, because they tend to lose money treating them. Insurance reimbursements — which are roughly based on what Medicare pays — are paltry. In the case of free-flap surgery, plastic surgeons can charge $7,000 to $25,000 per breast; the average Medicare reimbursement in 2007 was $1,737. As a result, some doctors won’t accept insurance for reconstructive surgeries, forcing patients to pay out of pocket. Others steer patients toward more profitable types of reconstruction, regardless of what’s best medically, says Mark Sultan, M.D., my reconstructive surgeon and chief of the division of plastic surgery at St. Luke’s-Roosevelt Hospital Center and Beth Israel Medical Center in New York City. Insurers reimburse implant reconstruction at roughly the same level as a flap, but surgery takes only about an hour. “Doctors may think, Why do a six-hour operation when I am paid the same amount for a one-hour implant?” Dr. Sultan says. “They may convince themselves, consciously or unconsciously, that the patient is a better candidate for an implant.”
In this climate, a mere 16 percent of women with breast cancer receive reconstruction at the time of their mastectomies, Dr. Alderman found; and only 10 to 15 percent of mastectomy patients get it later. The numbers also show vast regional and racial disparities, as black and Hispanic women are half as likely to receive reconstruction as whites are. “What’s the ‘right’ rate?” Dr. Alderman asks. “It’s when women are well informed and each chooses the option that’s right for her. I’m not sure that’s happening.”
‘I couldn’t bear the thought of losing a breast’
When Robin Miller, a 50-year-old dot-com employee in Los Angeles, contemplated surgery for her stage II breast cancer a few years ago, “I couldn’t bear the thought of losing a breast,” she says. So she readily agreed when her oncological surgeon suggested a lumpectomy, common for women with tumors smaller than 4 centimeters. (Miller’s was 2 cm.) She was given the option of mastectomy, but she recoiled at the idea. Her doctor didn’t discuss immediate reconstruction, nor did Miller get or seek a referral to a plastic surgeon.
For certain women, especially those whose tumors are large relative to their breast size, “breast conservation” surgeries can be anything but. Nearly a third of lumpectomy patients are unhappy with their cosmetic outcomes, according to a 2006 study by the University of Texas Health Science Center at San Antonio. Talking to a cosmetic surgeon as early as possible can help women choose the procedure that is best for their situation, but Dr. Alderman found that’s not happening — although women doctors in her research were twice as likely to refer patients to plastic surgeons as men were. “Many general surgeons want to do their surgery and move on,” Dr. Sultan says, and they assume the patient can get reconstruction later.
But “later” might never come, says Andrea Pusic, M.D., a plastic surgeon at the Memorial Sloan-Kettering Cancer Center in New York City: “Psychologically, there is a fork in the road, and once women go past it, they don’t come back.” A second surgery, with its costs and stress, can be less than appealing. Immediate reconstruction generally allows for “a better cosmetic result with fewer scars,” Dr. Alderman adds. “The patient wakes up with a breast or in the process of getting a breast, so it cushions some of the psychological trauma.”
The best approach for patients may be a breast-care team: a general surgeon, a plastic surgeon, an oncologist and a radiation therapist, or another mix of specialists who can come together to offer evaluations. It’s an approach now used at major cancer centers such as Memorial Sloan-Kettering and the Norris Cotton Cancer Center at Dartmouth-Hitchcock Hospital in New Hampshire. Memorial Sloan-Kettering has an optional class for women considering reconstruction and their loved ones, so no one lacks for information.