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Breast Advocate’s Founder Dr. Minas Chrysopoulo this month had the honor of moderating a panel on the importance of shared decision-making in breast reconstruction at this year’s American Society of Plastic Surgeons (ASPS) annual meeting in Chicago. ‘The Meeting’ is the largest plastic surgery meeting in the World and welcomes surgeons from all over the globe. Dr Chrysopoulo had the privilege of being joined on the panel by Breast Advocate co-contributor Dr Hani Sbitany, and patient advocates Terri Coutee and Kirstin Litz.
“Once upon a time, I’d tell a patient their breast reconstruction options and the associated risks and recommend what I thought was best. Then I discovered shared decision-making and it changed my practice forever,” shared Dr. Minas Chrysopoulo.
What exactly is “shared decision-making”?
Shared decision-making is the conversation and information exchange that happens between a patient and their healthcare professional to reach a treatment plan together. The doctor ensures the patient is fully educated about all their treatment options and the associated risks, while the patient shares their preferences, values and any other personal factors that are important in reaching the best plan for the patient.
Shared decision-making flies in the face of the paternalistic approach to healthcare delivery and instead empowers patients to have an equal voice in their treatment planning – It was the driving philosophy behind the creation of the Breast Advocate App.
Listen to the entire shared decision-making presentation here.
Autologous fat grafting, or “lipofilling”, is widely used in conjunction with breast cancer surgery:
1. it can correct partial breast defects after lumpectomy
2. it is used in conjunction with other breast reconstruction techniques to optimize breast contour and improve the final cosmetic results after both implant-based and autologous (flap) reconstruction
3. it is the primary breast reconstruction technique in male breast cancer patients
4. it can fill in contour defects and improve chest soft tissue padding after mastectomy in patients choosing to go flat
Fat grafting has also been shown to improve scar appearance, improve breast pain, and even reverse the soft tissue effects of radiotherapy (such as fibrosis).
The procedure involves liposuctioning from one part of the patient’s body, purifying it and then injected into the breast. It can be performed in conjunction with other breast procedures or as a stand-alone procedure. There are several fat grafting techniques that are used by plastic surgeons. There is no “set way” that has been shown to be the best in terms of long-term results. However, studies have shown that regardless of the technique used, the collection, handling, and transplantation of the fat cells must be optimized to obtain the best long-lasting results.
Despite the associated benefits, fat grafting in patients with a history of breast cancer has been somewhat restricted by 2 main concerns: the fear that it can interfere with breast cancer imaging, and that the regenerative cells could increase the risk of local breast cancer recurrence.
Some of the injected fat can turn hard after lipofilling. This is known as “fat necrosis”. Areas of fat necrosis cause calcifications (macrocalcifications) on mammograms. However, previous studies have shown that these macrocalcifications do not interfere with subsequent detection of breast cancer. The question regarding the risk of recurrence remains a topic of debate due to animal studies that have shown adipose-derived stem cells can stimulate cancer growth in nude mice. Although we don’t truly know whether the interaction between human fat tissue and cancer cells injected in immunodeficient mice can accurately reflect what happens in people, this uncertainty has led to obvious concerns about lipofilling patients with a history of breast cancer, particularly after a lumpectomy.
A recent study aimed to answer whether patients with breast cancer treated with autologous fat grafting are at an increased risk of cancer relapse compared with those who receive conventional breast reconstruction alone. No significant difference in the rate of local recurrence was seen after a 5-year follow-up. These findings confirm the results of previous studies; there is no clinical evidence to suggest that autologous fat grafting increases the risk of local breast cancer recurrence.
Research data pulled from nine separate clinical trials has shown that women choosing to undergo breast conservation (ie lumpectomy and radiation) have an overall rate of local recurrence at 5 years of less than 5%. This statistic compares similarly with mastectomy local recurrence rates.
The study shows “that in the modern era, the rate of local recurrence after breast-conserving surgery is quite low — lower than what has often been used historically to counsel women. These modern-era estimates should be used to inform discussions between patients and surgeons regarding the decision between breast conservation and mastectomy.”
It is important for patients diagnosed with breast cancer to fully discuss all their surgical options with their breast surgeon. They should also consult with a board-certified plastic surgeon before undergoing breast surgery whenever possible. Regardless of whether a patient chooses a lumpectomy or mastectomy, oncoplastic surgery and breast reconstruction options should be offered to all patients and fully discussed prior to any breast cancer surgery.
Breast Advocate App contributor, Dr. Hani Sbitany, discusses an alternative approach to traditional implant-based breast reconstruction in this NY Times article published yesterday.
For the past 30 years, the traditional method of implant-based breast reconstruction involved placing tissue expanders and implants underneath the chest wall muscles. It has been long believed that this muscle coverage offered lower rates of both infection and heavy scar tissue formation (capsular contracture) around the implant.
However, placement of a tissue expander or implant under the main chest muscle (pectoralis major) comes with certain risks to the patient. Specifically, the dissection and stretching of the muscle to fit the implant underneath, may increase the discomfort associated with the reconstruction, due to muscle spasm and tightness. Furthermore, in submuscular reconstruction, the pectoralis muscle heals to the overlying skin of the reconstructed breast, and in some patients moving forward, each contraction of the pectoralis muscle pulls the skin of the breast with it, causing breast animation or hyperanimation. This means that the breast temporarily becomes distorted and moves in an unnatural way when the patient uses her chest muscle.
Now some surgeons are placing the implants on top of the muscle in an effort to reduce complications like pain, weakness and “hyperanimation” deformities that can occur when the chest muscles are flexed. Results so far are extremely encouraging.
After being in remission from breast cancer for a year, Shannen Doherty underwent breast reconstruction surgery in May, reports People magazine.
She chose DIEP flap reconstruction. This procedure uses a patient’s own skin and fat from the lower tummy to recreate the breast following a mastectomy. Because of Doherty’s thin physique, she had to gain a little weight before surgery. The surgeon performed what is referred to as a “Stacked DIEP” which is a great option for thin patients. The “stacked” version of the DIEP flap procedure uses tissue from both sides of the lower abdomen to reconstruct a single breast. The standard DIEP flap procedure uses one side of the abdomen to reconstruct each breast.
Usually, when women select DIEP flap surgery they are looking for the best long-term solution to breast reconstruction since tissue reconstructions age with them — the reconstructed breast(s) gain weight when they gain weight and lose weight when they lose weight. The tissue ages more naturally and, unlike implants, these reconstructions never need to be redone.
It is important for patients to know implants are not the only option for reconstructive surgery. Unfortunately, advanced procedures like the DIEP flap are not offered by all reconstructive plastic surgeons since extensive experience in microsurgery is required to perform these surgeries successfully. Patients must therefore do their homework in finding surgeons with the appropriate expertise.
Black women in the U.S. are 40 percent more likely than white women to die from breast cancer. To address this disparity, the Susan G. Komen breast cancer organization has launched a campaign called “Know Your Girls.”
“The first step to closing this health disparity is to help black women take charge of their breast health by knowing their risk, knowing their bodies, getting screened, and talking with their doctors,” says the organization’s founder, Susan G. Komen. “By giving black women the tools to take charge of their breast health, we hope to help avoid unnecessary breast cancer deaths.”
Breast cancer treatment is changing . . . and in a big way! A landmark study suggests that women with a common form of early-stage breast cancer can safely avoid chemotherapy without increasing the risk of recurrence.
The TAILORx study found that genetic testing on tumors could identify women who can safely skip chemotherapy. Rather than enduring the harsh side effects of chemo, such patients can take a drug (like tamoxifen) that safely blocks the hormone estrogen or stops the body from making it.
The results of this study could enable up to 70,000 US patients annually to avoid chemotherapy.
Following a breast cancer diagnosis, women still need regular screening. However, a recent study shows many women are not following through with getting the recommended screenings they need.
The study followed over 27,000 women after their initial breast cancer surgery. The results showed one year after surgery, 13% of women had NOT had a mammogram. Over five years, only 50% of women had at least one mammogram each year.
The study also found that black women were less likely than white women to get an annual mammogram. “Lack of screening may contribute to higher death rates among black women, because recurrence of breast cancer is a major cause for poor outcomes in black women,” the researchers said.