Breast cancer survivor Janice Collins gave silicone implants the benefit of the doubt not once, but twice: The first surgery resulted in an infection, the second in a lopsided breast. Only a chance meeting with another breast cancer survivor led her to investigate the DIEP flap, a reconstruction that would use her own abdominal tissue to build a breast that feels and looks natural.
"Not even my own doctor had mentioned this procedure to me," says the 61-year-old probation administrator, who ultimately received a DIEP flap and couldn't be happier with it.
The technique is just one of several advantageous treatment options — for hip arthritis, uterine fibroids, depression, and other conditions — your doctor may not tell you about.
The reasons are multiple: Your doctor may lack training in new, cutting-edge surgeries; it may be harder for him to obtain insurance coverage for a particular procedure; or he may simply be cautious about treatments that don't have decades of data backing them up. However, that doesn't mean you wouldn't want to be aware of all your choices — and have the chance to make the most educated decision about your health care. Here are four you should know more about.
The usual treatment: If you develop mild to moderate forms of osteoarthritis of the hip in your 40s, you're usually told to wait until you're 55 or 60 for a full or partial hip replacement, in which the entire neck and head of the thighbone (the femur) or just the head are replaced with metal parts. Though it may mean tolerating limited movement and chronic pain, there's a reason for waiting: Metal hips last up to 20 years, and in a recent British study, they lasted this long in only half of osteoarthritis patients under age 40.
Pros: Available to middle-aged arthritis sufferers; marked pain improvement in almost 98% of recipients 5 years later; nearly all patients satisfied
Cons: Data goes back only 9 years; unclear how long resurfacing delays full hip replacement. Femur fractures occur in 1.5% of patients, though they're twice as likely in women; a doctor should check your bone density first
falseSmart option: Hip resurfacing. In this procedure, surgeons reshape the top of the thighbone and cover it with a metal cap that sits inside a thin metal hip socket, blocking painful nerve endings on both sides. More bone is left intact than with a replacement, which makes any future surgeries or adjustments easier to perform and more likely to be successful.
Why it may be better: Instead of suffering for years until they qualify for a hip replacement, patients experience "a nearly complete end to pain," says William Macaulay, MD, director of the Center for Hip and Knee Replacement at New York–Presbyterian Hospital/Columbia. The FDA-approved Birmingham Hip System was still providing pain relief 5 years after surgery in 98% of patients during clinical trials. In foreign studies, 98% of resurfacing recipients in eight countries were satisfied 7 years later.
Why it's kept quiet: Hip resurfacing hasn't been available in the United States for very long — the procedure was approved by the FDA in 2006 — and some doctors with many years of hip replacement experience are skeptical because it's so new, says James Rector, MD, an orthopedic surgeon in Boulder, CO. Additionally, there's not much long-term data on its efficacy yet — only 9 years' worth, to be exact. These factors explain why it makes up less than 4% of current US hip surgeries.
Real-life endorsement: By age 42, Charlie Post had arthritis in his left hip that made it impossible for him to sleep comfortably, and the Bantam, CT, resident could no longer hit the ski slopes with his three teenage sons. Three different doctors told him he was too young for surgery. "One said I'd have to be walking with a cane before I had a total hip replacement," Post says. A year later, he read about resurfacing on the Internet; less than a month after surgery, he was almost entirely pain free and able to sit comfortably in cars and planes again — even skiing with his sons by the end of that season. Though he might still need a replacement someday, "ultimately, it was worth it," he says.
The usual treatment: For these painful noncancerous growths, many doctors suggest a hysterectomy — removing the uterus — as the "first line of defense," says Michael Broder, MD, president of the Partnership for Health Analytic Research in Los Angeles. In fact, about 60% of all hysterectomies are for uterine fibroids. The surgery virtually guarantees a cure but is not for women who want more children or fear psychological distress from such surgery.
Smart option: Uterine fibroid artery embolization (UAE). During this uterus-preserving procedure, a radiologist threads a catheter through the groin and into blood vessels going to the uterus. Tiny plugs block the blood supply, shriveling the fibroids.
Why it may be better: The womb-preserving procedure reduces heavy bleeding, pain, and pressure about 90% of the time, according to studies by UCLA and Thomas Jefferson University. Patients who get UAE have less pain on average a day after the procedure than those who undergo hysterectomy or myomectomy (a laparoscopic procedure), average a shorter stay in the hospital (4 days or less, compared with 6 for hysterectomy or myomectomy), and return to work quicker (about 20 days, versus 62 days after hysterectomy or myomectomy).
Why it's kept quiet: Turf wars between medical specialists and uneven insurance coverage are two big reasons, say experts. "Gynecological surgeons feel they're giving their business away to radiologists if they suggest UAE over hysterectomy," says Francis Hutchins, MD, an adjunct professor of obstetrics and gynecology at Drexel University who has published studies on UAE. The numbers illustrate the divide: In an unpublished pharmaceutical study of surgically treated fibroid sufferers, 83% had a hysterectomy, 15% had a myomectomy, and just 2% had UAE, according to Broder.
Real-life endorsement: Like most women over 40 hospitalized with severely bleeding fibroids, Kathy Moore was scheduled for a hysterectomy. But the Washington, D.C.–area resident found it unacceptable. "The emotional trauma of that would have taken me years to get over," says Moore. Three years ago, she decided to try UAE. "The bloating, cramping, and heavy bleeding are now just a memory."
The usual treatment: Antidepressants, talk therapy, or a combo of both.
Smart option: Electroconvulsive shock therapy (ECT) Hollywood portrayals such as "One Flew Over the Cuckoo's Nest" and "Requiem for a Dream" haven't won "shock therapy" many fans, but it's no science fiction: Studies show ECT offers remarkable symptom relief.
Today, outpatients are given general anesthesia and a muscle relaxant, so there are no dramatic muscle convulsions. The treatment lasts just a few seconds, and patients wake up a couple of minutes later. Scientists are still unclear how exactly it works (just as they are with more accepted antidepressant meds). ECT is administered 6 to 12 times over 1 month, depending on a patient's needs, according to the American Psychiatric Association.
Why it may be better: ECT boosted quality of life in nearly 80% of patients, Wake Forest University School of Medicine researchers found, and it relieved depression symptoms for 83% to 95% of patients in a North Shore–Long Island Jewish Health System study — a greater success rate than the 50% to 70% who improve on antidepressant meds.
Why it's kept quiet: Though an estimated 19 million Americans are depressed in a given year, just 100,000 adults receive ECT annually, in part because of its past: Risks in the 1930s and 1940s were due to misuse of equipment, incorrect administration, and improperly trained staff. Today, given correctly, one of the main concerns is that ECT patients often develop varying degrees of memory impairment, says Charles Welch, MD, a psychiatrist at Massachusetts General Hospital in Boston. About 12% of patients suffer amnesia for as long as 6 months after treatment, especially if they're female (memory problems last just 4 to 8 weeks when electrodes are placed on only one side of the head). Because of this and the associated costs — private insurers may approve only a few sessions at a time — APA guidelines state it's best for patients who haven't responded to meds or who prefer ECT to other treatments. Still, "There is an inappropriate reluctance on the part of psychiatrists to refer people to ECT," Welch says.
Real-life endorsement: Former Massachusetts First Lady Kitty Dukakis turned to ECT in 2001 after 17 years of depression that resisted other antidotes. She still undergoes a six-treatment series every 10 months. The memory loss she experiences — forgetting phone numbers and directions, mostly — are "a trade-off. I needed something much more dramatic than what antidepressants did for me," explains Dukakis, 71, who chronicled her experience in the 2006 book "Shock: The Healing Power of Electroconvulsive Therapy." After the initial round of ECT, "I just felt that relief immediately," she says. "I remember waking up and seeing my husband and smiling — and I had not smiled for a long time. It has changed my life."
The usual treatment: Federal law requires insurers to pay for breast reconstruction after a mastectomy — however you choose to do it. Yet the overwhelming majority of women are offered only saline or silicone implants.
Smart option: The DIEP flap. In this sophisticated operation, a plastic surgeon moves a patient's abdominal skin and fat to her chest, transferring and reattaching blood vessels and sometimes nerves in the process. Named for the deep inferior epigastric perforator abdominal blood vessels that are used, the DIEP flap is an advancement of the TRAM flap, a more common, slightly easier technique that sacrifices grafted abdominal muscles to build a new breast. The DIEP flap leaves these abdominal muscles intact — the surgeon pushes them aside briefly to remove tissue behind them.
Why it may be better: "Preserving the abdominal muscles means you can still lift your kids and do all your daily activities," says John Hijjawi, MD, an assistant professor of plastic surgery at the Medical College of Wisconsin. There's also a chance you can regain sensation in your breast: A study of 24 women at Methodist Hospital in Houston found that every woman who received a nerve transfer regained some sensation within 6 months. Patients have less post-op pain, a shorter recovery, and fewer abdominal hernias than those who get TRAM flaps, according to the University of Texas M. D. Anderson Cancer Center and Mayo Clinic studies, and a lower risk of the complications associated with implants (such as pain, asymmetry, and the need for future surgical replacement). The DIEP flap's emotional benefits are also significant: "Many women don't think of it as a reconstruction — they think of it as a real breast," says Joshua L. Levine, MD, a plastic surgeon in New York.
Why it's kept quiet: Less than 100 surgeons in the country can do the surgery; thus, just 7% of US breast reconstructions in 2006 were DIEP flaps, says the American Society of Plastic Surgeons. And despite the Women's Health and Cancer Rights Act requiring insurers to cover postmastectomy reconstruction, surgeons and patients "may have to jump through hoops" to get coverage for the $30,000-plus DIEP flap surgery, admits Levine, delaying surgery for months or years.
Real-life endorsement: One Ohio breast cancer survivor fought for 18 months before her insurer approved DIEP flap coverage. "All of us want to live, but you want a quality of life after cancer, and insurance companies are holding walls in front of women," says the 54-year-old, who requested anonymity because she's forbidden to discuss her insurance settlement. Despite the long wait, she says, "it is still the best thing I ever did."