Resources for Navigating Breast Cancer Care During the COVID-19 Pandemic
The COVID-19 pandemic has impacted everyone across the globe. Confusion, fear, and safety protocols continue to make navigating breast cancer screenings and treatment more difficult than ever. Although data and recommendations are constantly evolving, we present some helpful information below to address the most common questions we see relating to breast cancer care during the pandemic.
Breast Cancer Screening
Leading health organizations and medical professionals agree it is safe to resume breast cancer screening. The importance of resuming annual screenings and/or diagnostic imaging tests cannot be understated. With safety protocols in place at every medical facility, patients can more confidently go to these appointments as long as they adhere to the recommended guidelines, such as wearing a face mask/covering and physical distancing as much as possible.
Treatment Options
Many patients today are reporting delays in their breast cancer surgery due to the limitations in place within hospital systems. These limitations help ease the burden on the healthcare system created by COVID-19. The impact of these delays has raised obvious concerns from patients and medical professionals alike.
Luckily, more hospitals and surgical centers are opening up and breast cancer surgery delays are becoming less frequent. Currently, treatment options like chemotherapy and radiation are continuing as normal and patients should follow their healthcare team’s recommendations.
As a helpful resource, the American Society of Breast Surgeons has published recommendations to help guide physicians and their patients through the common scenarios related to breast cancer treatment during the COVID-19 pandemic.
COVID-19 Vaccines
Vaccine distribution regulations vary by state, but in many areas breast cancer patients are eligible to receive the vaccine now. Before receiving the COVID-19 vaccine, patients should consult with their medical team.
There’s a lot of confusion among breast cancer patients as to whether the vaccine is a good idea or a bad idea for somebody undergoing treatment. Reports of lymph node swelling after a vaccine that mimicks breast cancer spread (metastasis) has obviously caused a lot of concern. However, this should not be mistaken for disease progression. It is also very understandable for some of you to feel uncomfortable receiving a vaccine that is so new and has been developed so quickly. However, please know that new vaccines cannot be released for public use without the appropriate safety protocols being followed.
Breast Reconstruction Timing
For many, breast reconstruction has had to be rescheduled or postponed due to their local hospital infection rates and bed capacities. This can be extremely frustrating to say the least. However, please know that delayed reconstruction is still possible any time after a mastectomy (or lumpectomy).
For current scheduling availability and recommendations in your area, please keep in close touch with your plastic surgery team.
Related content:
Coronavirus: What Breast Cancer Patients Need To Know
The Impact of COVID-19 on Breast Cancer Treatment
Breast Advocate Founder Answers Your COVID-19 Breast Cancer and Breast Reconstruction Questions
Rescheduling Elective Breast Surgery After COVID-19
COVID-19 Patient Outcomes After Breast Cancer Treatment
Breast Advocate Proudly Supports Breast Reconstruction Awareness (BRA) Day
Breast cancer is the most commonly diagnosed cancer in women (after skin cancer), yet less than half of American women are offered the option of breast reconstruction after mastectomy or lumpectomy. Likewise, less than 25% of women are provided information on ALL breast reconstruction options available to them.
BRA Day’s primary mission aims to change these statistics! The annual Breast Reconstruction Awareness Day is celebrated on October 21st this year. According to the Plastic Surgery Foundation, the purpose of this day is to “educate, engage and empower women to make the decision that is best for them following a diagnosis with breast cancer. That involves informing women, family members, caregivers and the media that the breast cancer loop remains open until a woman is informed of breast reconstruction options.”
The mission of BRA Day is very much aligned with Breast Advocate’s! Co-created by leading specialists and patient advocates, Breast Advocate is a free breast cancer app that provides evidence-based information and treatment recommendations, personalized for users. These recommendations include a vast amount of information on ALL breast surgery options, including all types of reconstruction, and the option of no reconstruction. With the personalized information in a patients hand, it is our hope to empower individuals to have the conversation they want to have with their medical team.
In honor of BRA Day, Breast Advocate founder Dr. Minas Chrysopoulo joined BRCA Strong to discuss breast reconstruction options available to women and men today. Watch it below:
5 Things You Should Know Before Having Breast Reconstruction Surgery
Breast implants are NOT the only option
The most commonly performed method of breast reconstruction performed today uses tissue expanders and implants. Although this approach is a good option for many, it’s not the only option. Likewise, implants may not be the best option for some patients. Reconstruction options using your own tissue (referred to as autologous or “flap” reconstruction) is also an option. In particular, after radiation treatment flap procedures are associated with fewer complications than implant-based reconstructions.
Sensory nerve reconstruction may be an option
Following a mastectomy, many patients experience permanent numbness to the chest area and reconstructed breast. This is because the sensory nerves that provide feeling are usually cut during the mastectomy. There is some good news though! Advances in breast reconstruction techniques have made sensory nerve reconstruction possible: reconnecting the sensory nerves in the chest can significantly improve the return of feeling to the reconstructed breast.
Enhanced Recovery After Surgery (ERAS) protocols are making recovery easier
Many surgeons are now implementing ERAS protocols to ensure their patients experience an easier recovery following breast cancer surgery, with or without reconstruction. Regardless of the type of reconstruction performed, ERAS protocols are reducing hospital stays, shortening recovery, and reducing the need for narcotics to control discomfort after surgery.
Shared decision-making matters
Breast reconstruction is not a one-size-fits-all procedure. Ensuring you discuss all your options and how they align with your lifestyle, preferences, and goals is critical in planning the best reconstructive option for you.
You can choose NOT to have breast reconstruction
It is important for patients to remember choosing NOT to undergo breast reconstruction and instead opting to “go flat” is an acceptable choice. Going flat (aesthetic flat closure) gives patients seeking no reconstruction the ability to maintain balance and symmetry without reconstructing the breast(s). Women can also choose to go flat after breast reconstruction if they are unhappy with their reconstruction results or have experienced complications after breast reconstruction.
To learn more about ALL your options, download the Breast Advocate App today!
Breast Advocate Founder Joins BRAVE Coalition to Discuss Rescheduling Elective Breast Surgery After COVID-19
Why is there so much confusion on whether elective cases (including breast reconstruction) can start to resume?
Yes, there’s lots of confusion, especially as it relates to a hospital setting versus other surgery centers. Obviously, a lot of a lot of plastic surgeons operate either out of their offices or they have operative suites. Many of them have surgery centers or ambulatory surgical centers. There has been a lot of mixed messaging and some confusion for sure.
For us [in San Antonio], we are operating again. I am very happy with the procedures in place at the local hospitals in terms of testing. I am one of those who believes that we need testing for all patients. Personally, I would not be comfortable offering [breast reconstruction] surgery to people right now without pre-operative COVID-19 testing. There are pros and cons to every approach but that’s just my take.
We must have consistent, good, safe practices and protocols for everyone. Specifically, the surgical community fears operating on asymptomatic positive patients (someone who is positive who doesn’t know it because they’re not showing any symptoms). There’s some data out there that suggests that positive patients who are asymptomatic are at higher risk of developing post-operative complications. You’ve got to take that data seriously.
There was a study out of China that looked at elective patients having surgery (various specialties not just breast reconstruction). They looked at patients who were actually, in retrospect, positive for COVID-19 but at the time hadn’t shown any symptoms so they would have passed all verbal screening measures. Many of those patients ended up getting complications after surgery that otherwise you wouldn’t have expected them to have. There was a very high rate of pneumonia and mortality. Mortality was actually 20%. There’s lots of other data you have to take into account too. What’s the risk of someone being an asymptomatic carrier, what’s the rate of infection in the community…?
In San Antonio, only 10% of people being tested for COVID-19 are coming back positive. But, without mass testing you don’t know what the baseline rate of infection is.
There is a school of thought that’s a lot less restrictive… If you have a low risk patient who hasn’t had any obvious exposure, who passes all the verbal screening and physical screening (no symptoms, normal temperature, normal oxygen saturation on a pulse oximetry)… you don’t need testing on that person. That’s a track that some surgeons are pursuing and there’s definitely some value and an argument to pursue that line, and to reserve testing for only the high-risk group.
I don’t want people to take away from this that if your surgeon doesn’t test you pre-operatively, then you shouldn’t be having the surgery…that’s not what I’m saying. You have to take into account your individual situation, the geographic location, what’s going on where you are, and just have a very honest conversation with your surgeon, and talk about the protocol [they’re using].
Breast Advocate Founder Answers Your COVID-19 Breast Cancer and Breast Reconstruction Questions
Breast Advocate founder Dr. Minas Chrysopoulo recently answered patient questions on all things COVID-19 and breast cancer/breast reconstruction live on Facebook. During the educational hour, ‘Dr. C’ touched on topics ranging from how Coronavirus is spread, who is at high risk and the impact this outbreak is having on breast cancer surgery and breast reconstruction scheduling. Catch the replay here…
Question: What is COVID-19?
Answer: COVID-19 is the disease caused by the Coronavirus. The formal medical name for the Coronavirus is “SARS CoV-2”. It’s important to note that this virus has nothing to do with the flu. It’s been compared to the flu, but it’s not actually a type of flu. It’s not an influenza virus (the virus family that causes the flu), but some of the initial symptoms can be similar. The symptoms of a COVID-19 infection can be fever, a dry cough, shortness of breath especially on exertion (if you’re doing something that’s usually easy and all of a sudden you’re a bit short of breath, then this may be the first symptom you have), fatigue, poor appetite, headache, and some people also have GI symptoms like diarrhea. Please don’t go and hoard toilet paper…there’s really no need! It’s important to bear in mind too that at least 25% of people who become infected with the coronavirus never develops symptoms. That’s why social distancing is really important! Stay six feet from anyone when you leave the house. Obviously inside the house with your loved ones it’s very difficult to stay six feet away and there’s really no need to social distance from them, unless there’s a concern a family member has been exposed. In that case, please try at all costs if it’s possible to separate that individual from the rest of the family.
A lot has been made of the fever because it’s such a common symptom. However, you don’t need to have a fever to have COVID-19. In fact, all of those symptoms I mentioned above can occur on their own. For example, I have a very close friend who was recently admitted to hospital for care and he just felt fatigued for many days before the shortness of breath started. He never actually had a fever at all and we are hearing about more and more of those cases.
Question: How is COVID-19 spread?
Answer: First and foremost, this is a respiratory disease. The virus attacks your lungs first before it attacks anything else. That’s how it really tries to get a hold of your body, through your lungs. Coughing, sneezing and even breathing can spread the virus. Anything that releases droplets into the air can spread the virus. That’s why social distancing is really being emphasized because the best way to protect yourself is to stay away from others — at least six feet. You can also develop the inflection through touching someone who’s infected or by coming into very close contact… The virus can get on your hand and then enters your body when you touch your face. If you touch your mouth, your nose or your eyes that’s how the virus gets into your system, because it was on your hand.
Coronavirus can stay alive outside the body for many hours, and depending on the surface, up to many days. Metal surfaces in particular can have corona virus on them (eg doorknobs and shopping carts). The virus can stay on metal up to 3-5 days according to some studies. When you look at the cruise ship data, there’s some evidence that the virus can live up to nine days. If that’s true it probably has to do with environmental conditions like sunlight and heat. We just don’t know quite frankly, but what we do know is the virus survives on metal for at least three days. So if you have to go to the grocery store wipe down the cart. I would also recommend that you wear gloves. There’s been a shift in terms of the recommendations for face masks. Initially the CDC and the World Health Organization stance was that you didn’t need to wear a face mask unless you were sick. The reason for that being that face masks really weren’t that protective if you weren’t sick already and the reason to wear a mask was basically to keep the virus to yourself and to prevent spreading it. But I’m sure those of you who have been watching the news and the images from around the world from the countries that have dealt with the virus more successfully than the US (places like South Korea, Hong Kong, Singapore), the public is walking around with masks. Now the sense is that there’s something to that and even though face masks won’t protect you 100%, the recommendation now has shifted. I would say if you’re going out to a store or grocery store wear a mask of some sort. If you don’t have a mask wear a bandanna over your nose and your mouth. It’s better than nothing. I do feel very strongly that we have to prioritize the safety of our first-line health care workers. A lot of them are dealing with patient after patient who are infected. Our first-line health care workers must be prioritized in terms of surgical face masks and other personal protective equipment. But, in terms of what our patients should do…if you have a cloth mask at home — use it.
Question: What can individuals do to protect themselves?
Answer: In addition to what we’ve just said, think about what you’re touching. Hopefully you’re all social distancing and are staying at home. If you’re not, you should be. It’s the only way to stop the transmission. If you think about people as dominoes, when you line up dominoes and then you flick the first one, each domino falls over one after another after you flip the first. Now imagine each domino is a person. The virus spreads from person to person, just by being close to each other. The first person who gets infected potentially infects three other people. The only way to stop the dominoes from falling is to move a couple of dominoes out of the way so that when a domino falls it doesn’t touch the next one and doesn’t push the next one over. That’s how social distancing works — the infection stays in those who are infected, doesn’t spread, and eventually it dies out and that individual hopefully gets better. Most people do get better! For 20% of people who get symptoms, the symptoms are mild. Another 20% of folks will have more severe symptoms but probably won’t need to be hospitalized. It’s only about 10-15% of people who get the infection that will need hospital care and of those, it’s about 5% that will have severe breathing problems that will potentially need the intensive care unit and ventilator support.
Question: Who is at risk for developing severe symptoms?
Answer: The elderly and people with underlying medical problems are most at risk. This includes those who have compromised immune systems. So obviously, patients with cancer are very much on that high-risk list. Now, if you’re a ten-year survivor or you’re ten years out from chemo, you’re not considered immunocompromised anymore and you’re not high risk. But, if you’ve just finished chemotherapy you’re high risk. If you’re going through cancer treatment right now, if you have a current cancer diagnosis — you’re high risk. If you’re over 60 yrs old, you’re high risk. If you have underlying medical problems like heart disease, lung disease, kidney disease, diabetes, asthma,.. you’re at high risk. So, you must protect yourself and really minimize your contact with the outside world. Minimize doctor visits as much as you can. Obviously, that’s impossible if you’re still undergoing cancer treatment and you need to go in to see your oncologist. But, if you’ve finished treatment or you’re not getting active treatment right now, don’t go for a routine screening mammogram or ultrasound. All those things can wait. The American Society of Breast Surgeons has recommended very strongly that all screening tests to be postponed.
Question: Why have hospitals cancelled breast reconstruction surgeries?
Answer: There are a bunch of recommendations now from American societies, including the American College of Surgeons, the American Society of Breast Surgeons and the American Society of Plastic Surgeons. Any breast cancer care that doesn’t involve surgery is essentially being prioritized wherever it’s safe to do so. If there’s any possible way you as a breast cancer patient can be treated right now without surgery initially, without it impacting your prognosis, then that’s the recommendation. For example, if your cancer can be controlled by hormone therapy, an aromatase inhibitor or you can have neoadjuvant chemotherapy first before your surgery, all that’s going to be prioritized. We want to keep people out of hospital as much as possible. The last thing breast cancer patients who are immunocompromised need is to go into surgery and be exposed to the virus. As I said, this affects your breathing, your lungs,.. your respiratory system. The last thing you want to do is go in for a surgery that could have potentially been delayed a little bit and then you end up on a ventilator because you contracted the virus. This is also about preserving resources to get all the COVID-19 infected patients through this and minimize the death rate. But please know, this decision from our societies in terms of breast cancer care is to protect you. Please remember that as a result, breast reconstruction (because the surgery is not immediately life-saving) is going to be postponed. Certainly here in Texas that’s the position. Ultimately your situation will depend on your diagnosis, stage and where you live (depending on the geographic situation and how bad things have gotten). It may also depend on your state laws. There have been several state laws that have been passed that prevent certain surgeries. Please talk to your medical team your and your surgical team about your specific situation. But generally-speaking, breast reconstruction is on hold because it’s not immediately life-saving. Unfortunately that really does prolong the process for many people. Lots of patients have now been caught in limbo but you will get through this. You will get your surgery. I don’t know when things are going to be back in terms of scheduling. Certainly for us, we’re looking at this in two week increments moving forward and it’s a very fluid situation. The infection numbers are changing, the projections are changing. It’s a day-by-day thing. We just have to prioritize everyone’s safety.
Question: When will people being rescheduled for surgery?
Answer: All I can say right now is people will be rescheduled as soon as it’s safe to do so.
Question: Can you get the virus again if you’ve already been diagnosed?
Answer: We think that if you get it once that you’ll be okay for this season. I mentioned at the beginning that coronavirus has been compared to the flu. In terms of immunity, it probably is quite similar. When you get the flu it doesn’t mean you can never get the flu again, but it does mean that if you do get the flu again it won’t be quite as severe. Your immune system does protect you somewhat for the following season. Obviously the flu shot is a big help! I’m not going to get into the whole pros and cons of vaccination. Personally everyone in my family will always be vaccinated because vaccines work. But let’s not talk about the pros and cons of vaccines here. Hopefully the vaccine for coronavirus or for COVID-19 will be available soon. When you look at how long it takes to develop a vaccine (and several companies are working on it already), realistically it’s not going to appear I don’t think before the beginning of next year at the very earliest. It looks like if you get COVID-19 now you should be okay and you probably not at risk of getting it again for a while. But we don’t know for sure how long can someone be a carrier. I don’t know the answer to that because without widespread testing we don’t know who is a carrier so we don’t know how long they’ve been carrying it. If you look at the lifespan of the disease, if you get through two weeks (which is why for folks who are in quarantine it’s two weeks to make sure that it that they don’t develop any symptoms) we think the virus kind of burns itself out. There have been a small percentage of people who have become infected and ultimately didn’t develop symptoms until beyond two weeks but that’s only about 1% of people who have been infected as far as we know.
Question: Is there any medicine that we can take to help?
Answer: No treatments have been proven to be reliably effective so far. Obviously there’s a lot of hope being put on hydroxychloroquine, a z-pack, and zinc as a cocktail but the data on that is very poor to be honest. In terms of vigorous scientific data, if you develop symptoms the only thing you can do really it’s make sure you stay well hydrated, and make sure you’re still eating as much as you can, and stay mobile. Don’t stay in bed. It’s supportive measures only really.
Question: Is there a blood test for antibodies to determine if you’ve already had COVID-19?
Answer: Yes. It’s coming. It’s not going to be widely available for a while, but yes.
Question: If someone completed radiation treatments eight years ago and they are 65 and they have a compromised immune system should they be going to work?
Answer: I wrote an article that’s published on BreastAdvocateApp.com. It’s about what coronavirus is and what breast cancer patients should know. There’s a whole list of precautions and advice, and one of those is if there’s any way you can work from home, do it. Again going back to social distancing…you know we’re at the point where this isn’t going to go away on its own. There cannot be life as usual. The best thing anyone can do to protect themselves is limit their risk of exposure. The only way to do that is to stay home and leave the house only when you absolutely must. When you go out be a minimum of six feet away from everyone. That means most people should be staying at home and working from home if that’s at all possible. Now I fully appreciate that unless it’s mandated by your individual state it’s very much left up to your employer, but please push it as much as you can to work from home.
Question: I was supposed to have prophylactic surgery this year but it’s been postponed. Should I ask my doctor about going on tamoxifen?
Answer: That’s a great question. Anyone who has a high-risk gene mutation, anyone who carries a gene mutation like the BRCA mutation (which is obviously the best known but certainly not the only one), should talk to their physician about steps that they can take that don’t involve surgery to see them through, until the point where they can get the risk-reducing surgery they want. Please also remember that non-surgical methods of risk reduction are chosen by a lot of people right off the bat. It’s a very valid way to go to decrease your risk. As I mentioned earlier, the screening aspect of it is going take a hit for the next few months, but you can definitely go on risk reducing medications like tamoxifen if you choose. That’s another option.
Question: If it does not impact prognosis and local hospital resources allow for a choice between hormone therapy or a mastectomy is it still preferable to opt for immediate mastectomy with DIEP flap later?
Answer: Well if it doesn’t impact your prognosis then you can also look at it the other way and ask, ‘why have the mastectomy if that can be delayed.’ From a strictly cosmetic standpoint, immediate reconstruction is going to be better. In some places you can still have your mastectomy and have a tissue expander placed. The tissue expander preserves the skin envelope and you can later have that expander exchanged for your DIEP flap, so in that sense you do get an extra surgery because the DIEP flap and the mastectomy aren’t being performed at the same time, but the tissue expander is used as a bridge between the two. Whether that’s an ‘acceptable’ way to go or not will depend on where you are and the situation.
Question: Once we get back to normal and you are allowed again to do surgery, how long would it take to be scheduled again?
Answer: Great question! But I don’t really know. I promise and surgeons across the globe will get everyone in as soon as they can. Unfortunately, some of you will have to wait a little bit longer then you want to wait, but we’re going to get everyone through as soon as physically possible. I promise!
Question: What is your advice for staying healthy while patients are waiting for the DIEP flap procedure and sheltering in place?
Answer: Great question! Nutrition and exercise! Don’t start any bad habits. Don’t start smoking. You can still drink, just use your best judgment and also obviously follow your medical oncologist’s guidelines in terms of alcohol because you may be on some other medications…it depends on what part of your treatment you’re in, etc. Just try to eat as healthy as possible and exercise. Aerobic exercise always improves healing so try and get some exercise in if you’re waiting for a DIEP flap. Specifically remember what your surgeons told you in terms of where you are with your specific weight. Sometimes losing a significant amount of weight can hurt you in terms of the DIEP flap procedure and how much tissue can be moved, and how much tissue there is to work with,.. or any other flap procedure for that matter. So I wouldn’t necessarily prioritize weight loss but I would prioritize healthy living as much as possible.
Question: What should individuals do about abdominal wounds that aren’t healing properly during this time?
Answer: It depends on the practice that you’re in, who your physician is and how they do it, but I’ll tell you how we’re doing it in my practice, PRMA. If one of my patients has a wound healing problem, the first thing we’re going to do is get on a telehealth visit and take a look at things to see how things look. Not all healing problems are the same, so if we see that it’s just a little bit of superficial scabbing or something like that, then a little TLC is all the patient needs. That person isn’t going to have to come in and increase their risk of coronavirus exposure by coming into a medical office. If it’s something that looks like it needs to be cleaned up and we need to maybe cut away a little bit of devitalized tissue to help things heal, then we’ll have you come in. We’re evaluating on a patient by patient basis. Let me also backtrack a little bit and tell you what we’re doing in the office again in case you do still have to come in for an in-person visit. Let’s say you do have a wound healing problem or we’re worried about an infection, or anything that cannot be dealt with over telehealth. We, for many weeks now, have been following the most aggressive approaches in terms of minimizing patient risk in the office so please be prepared. The nurse and the physician wear masks and gloves. It’s not personal, it’s for everyone’s protection. Everything is cleaned with antiviral detergents between every patient visit. Patient visits are staggered so the only person (other than your medical team) who will be in the office when you’re there will be you, unless it’s impossible to avoid that situation. That’s always going to be the primary goal. If there’s someone else already in the office and you have to wait a little bit for the appointment then you’ll be asked to wait in your car, and we will text you or call you (whatever works best for you) when we are ready for you to come in. We’ve got this really streamlined now. We take this exceptionally seriously and we’re only going to be bringing you into the office if we absolutely have to.
Question: I am a five-year survivor with asthma and on tamoxifen. Am I considered high-risk?
Answer: Yes, anyone with a breathing issue like asthma, chronic bronchitis, COPD, smokers, anyone who vapes, are higher-risk. You don’t have to smoke cigarettes; it includes pot as well. Anything you inhale other than air increases your risk because it really decreases your capacity to deal with a pulmonary insult. Anything that attacks your lungs is going to have an easier time if your lungs are compromised because you inhale stuff you shouldn’t on a regular basis. We have seen a lot of younger folks be hospitalized and we think that some of that is the extent of vaping in that age group.
Question: I am two-weeks post-op double mastectomy with DIEP flap. Because of COVID-19, will my phase 2 surgery be delayed?
Answer: Yes, all surgeries are off right now. So yes, unfortunately your revision surgery will be delayed. For surgery in our practice, most breast reconstruction patients get a second stage, or ‘tune-up’ surgery. Step one, the first surgery, is about making patients physically whole again. The second surgery is about making them look as good as possible. This addresses symmetry issues, size discrepancy, contour issues after mastectomy, and maybe some unevenness and scarring. If you have had DIEP flap surgery, we address the belly scar to smooth things out and smooth out the belly contour; basically, make things look as good as possible, that is stage two. So yes, all stage two surgeries are also delayed.
Question: Since I was scheduled for this week, I have been following pre-op instructions, should I continue?
Answer: That’s a good question, some of them you’ll need to continue, others not so much. Please email your surgical team and go through the list to see which of those you really need to be continuing, and which of these you can put on hold for now.
Question: I am assuming that the length of time for a tissue expander placement is not a problem? I have some family members that are concerned I have had a tissue expander in place for 2 years, and now it is up in the air – is there a limit on how long the tissue expander can be in place?
Answer: No, if you’ve got a tissue expander in place and you are not having any issues, you can keep that in for as long as you need to. So no, it is not a medical concern. It doesn’t impact your health if you’ve got no problems with it whatsoever. Rest assured, there is no urgency from a medical standpoint or health perspective. I know you’re probably dying to get it out, but medically speaking you’re fine.
Question: Can you demonstrate proper hand washing?
Answer: I can try. Okay, take off your jewelry. Warm water and soap will do it. Quite frankly if you’re in the kitchen and you’ve got dish detergent, that will work too. Warm water, and you’ve got to wash your hands for at least 20 seconds. There have been some pretty amusing songs on social media of people picking different songs. Do whatever you need to do that lasts 20 seconds to guide you. You get your hands wet with warm water, add the soap or detergent, lather up, get a nice foam. I would treat this kind of like a pseudo-surgery scrub. You know when we prepare for surgery, we obviously do a lot more than this, but this is kind of a pseudo-surgical scrub. So once you’ve done that for a few seconds, focus on every finger, and both thumbs, all the way around each finger, all the way around both thumbs. Then you rub one hand on top of the other, because you need to do that to really get into the web-spaces. Every web-space, and then again on the other side once again to finish off. Then get your jewelry, rinse that and wash it really well. This ring is metal, and the virus can live on metal for several days as we discussed earlier. So wash It really well, then put it back on and dry your hands. That’s it! 20 seconds, warm water, with soap!
Question: What is the optimal BMI for DIEP flap surgery?
Answer: Good Question. The optimal is high 20’s from a surgeon standpoint. When you get up to 25, this is the normal BMI, as DIEP flap surgeons, we like when patients are a little bit heavier, it’s a little bit easier to get more volume obviously. However, I wouldn’t encourage gaining weight. I really avoid doing that at all costs just to make someone a candidate for surgery. Some people are happier at a slightly higher weight and that is just fine. It gets harder to do DIEP flaps when the BMI starts to get down towards 20. Most women can still get a DIEP flap with a BMI of 20, but a lot of it obviously depends on how you carry the tissue that you do have, and where it is on your body. Some ladies with a BMI of 21 that have had a couple of kids, and they’ve got a little pooch as they call it. I had a lady the other day that referred to it as a kangaroo pouch, which I hadn’t heard before but that works too. Anyway, some tissue that they wouldn’t mind getting rid of, if that is over the lower abdomen we can use it. Now ultimately, in addition to how you carry your tissue, another big factor is your breast size and what your expectations of final breast size are. Also, whether you will reconstruct one breast or two. So a lady who is very thin, who needs one breast reconstructed who wants to keep the other to preserve sensation, or because the risk of the other breast is low,… in that situation we can use all the lower tummy for just the one breast. That’s often referred to as a ‘stacked flap’. But even ladies having bilateral procedures, so both breasts, can often have DIEP flap surgery even though a lot of surgeons will say “oh, you’re too thin”, or “you’re not a candidate”. It really does depend on how you carry your tissue. Even lower BMI patients, in the low 20’s can still be DIEP flap candidates. We see a lot of people in our practice who have been told elsewhere that they’re not a candidate for DIEP flap surgery for a variety of reasons. Previous abdominal surgeries,… very few prevent DIEP flaps from being possible. Certain types of abdominal surgery, if you have had a previous full tummy tuck, you’re not going to be a DIEP flap candidate, or if you’ve had major abdominal reconstruction you probably won’t be a DIEP flap candidate. There are a couple of those instances that we’ve pulled off too, but it depends very much case-by-case. If you really feel that DIEP flap surgery is for your, and you definitely want to look into it, if you’ve been told you aren’t a good candidate; I strongly recommend a second opinion. A second opinion can never hurt, even if it’s just to confirm what your first opinion was, at least then you know. Please by all means hit us up for a second opinion. We are here for you. We see a lot of people and talk to a lot of people who want a second opinion. Please use the PRMA Virtual Consultation form if that’s something you feel would be helpful for you. The other thing about DIEP flap and BMI is we tend to push the envelope in terms of high BMI and that is based on work that came out of our practice. That is a study we did that was led by Dr. Ochoa. So we looked at complication rates, and we found that patients with a BMI of up to 40 are candidates for the procedure. Above a BMI of 40 the complication rates really uptick. So the higher the BMI, the higher the line goes (in an upward motion). The higher the BMI, the higher the risk of complications. When the BMI gets to 40, the line stops being a gradual increase and heads more vertically. Now again, it depends on how you carry your weight. There are some ladies who have a BMI of less than 40 but the way they carry their weight; their risk will be more like a lady who has a BMI of over 40, so it is very much a case-by-case decision. This is the guide, so we really try to get our patients below 40 for DIEP flap surgery, it is just safer for the patient.
Question: What different platforms are you using for telemedicine and is insurance covering telemedicine?
Answer: There are several platforms — Skype and FaceTime are the two most popular. We are able to do it in a way that we don’t document anything in either of those platforms. Everything is documented straight into our EMR (electronic medical records) from a HIPPA protection standpoint. Skype and FaceTime are the most common platforms that we are using. Most insurance plans are covering it, but please confirm with your specific insurance carrier, so Please do check with your individual insurance carriers and plans to make sure that is the case.
The Impact of COVID-19 on Breast Cancer Treatment
Published March 31, 2020. Updated April 10, 2020
Breast cancer does not take a break…even amid a global crisis like the Coronavirus pandemic. For most people, it’s already overwhelming to hear the words “you have breast cancer”. In the midst of the current COVID-19 outbreak, increased uncertainty and changes in treatment recommendations are elevating everyone’s anxiety further. Many people are now being told that their treatment plan is changing. If you’re one of them, please know that your breast cancer team is adjusting your treatment plan to keep you safe and limit your exposure to coronavirus. Breast cancer patients are at increased risk of severe symptoms if they get coronavirus. People with severe symptoms need admission to a hospital for supportive care and are more likely to need intensive care, ventilator support for severe breathing problems, and are also at increased risk of death.
A recent study published in the Lancet, a highly respected medical journal, evaluated 34 patients who were infected with Coronavirus but didn’t have any symptoms, and underwent elective surgery. All developed pneumonia and 20% died.
All the medical and surgical societies are prioritizing your safety during this pandemic. At the same time as maximizing your safety, your team won’t do anything that negatively impacts your long-term prognosis.
Individuals Needing Chemo and/or Radiation
Most facilities providing chemo and radiation therapy treatment for breast cancer patients remain open and necessary treatment is not being delayed. Vigilant cleaning, health screenings of all patients before they enter the facility, and the advisement of patients to wear masks are just a few of the many steps healthcare workers are implementing to ensure patient safety. In many places, patients are no longer allowed to bring someone with them during their chemo treatments.
Individuals Requiring Breast Cancer Surgery
COVID-19 is impacting the surgical plans of many patients. At this time, the White House and numerous surgical societies are issuing guidelines recommending all surgeries that are not immediately life-saving be postponed. The American College of Surgeons and the American Society of Breast Surgeons are recommending delaying any surgery where a 6-8 week delay would not impact clinical outcomes. This includes surgery for DCIS, stage one ER/PR+ invasive cancers, re-excisions, surgery for high-risk lesions, and prophylactic (risk-reducing) mastectomies. Wherever possible, patients are being treated with hormonal therapy (eg Tamoxifen), aromatase inhibitors, or neo-adjuvant chemotherapy to enable surgery to be delayed. Recommendations are also calling for scheduled mastectomies to be converted to lumpectomies when clinically acceptable. Patients still wanting a mastectomy (with or without reconstruction) will be able to return for their definitive surgery once the crisis has passed.
Individuals Choosing Breast Reconstruction
For patients wanting breast reconstruction, there will unfortunately be a delay between the lumpectomy/mastectomy and the reconstruction procedure in most situations. In the US, some institutions are still allowing tissue-expander reconstruction, but the American Society of Plastic Surgeons (ASPS) strongly advises all autologous (flap) reconstructions be delayed. Although breast reconstruction is considered medically necessary, it is not immediately life-saving. For many, delaying reconstruction is understandably devastating, but it is important to remember there is no deadline for reconstruction and your health and safety are the top priorities of your surgical team.
Although reconstructive surgeries around the globe are being postponed, patients can still use this waiting period to research all their reconstructive options to determine which procedure is best for them. The Breast Advocate app provides personalized evidence-based information and recommendations for breast cancer surgery and reconstruction, after taking your situation and personal preferences into account.
Individuals at High Risk
At this time, individuals interested in prophylactic (risk-reducing) surgery because they are at high risk for developing breast cancer (eg BRCA+), should continue to self-monitor for breast changes at home. All society guidelines are strongly urging all prophylactic surgeries be postponed. Screening mammograms and MRIs may be delayed in your location during this pandemic. If any concerning breast changes occur, call you healthcare provider for further diagnostic instructions. Please also talk to your physician about the option of taking tamoxifen to decrease your risk while you wait for surgery.
It is important to remember that we must all do our part to protect ourselves, our loved ones, and our healthcare providers during this overwhelming time. By taking these measures, your risk of contracting COVID-19 will be minimized, hospital admissions will be reduced, necessary PPE will be conserved for our healthcare providers on the front lines, and lives will be saved.
Free App for Breast Cancer Treatment and Breast Reconstruction Decision-Making
A leader in breast cancer treatment education and shared decision-making, Breast Advocate® is excited to announce the release of our updated free app for breast cancer surgery and breast reconstruction. Thank you to our users for providing the valuable feedback that has helped make our app even better!
The latest updates greatly improve user experience and navigation, and give the innovative breast cancer app a fresh new look. Users can now customize the content they see on their dashboard via a personal feed, and easily find specific content using our optimized search engine.
Co-created by breast cancer specialists and patient advocates, the Breast Advocate® app provides anyone with breast cancer, a history of breast cancer, or at high risk for developing the disease a much needed voice in their treatment decision-making.
Should you have a lumpectomy or mastectomy? Should you have prophylactic surgery? Should you go flat or have breast reconstruction? If you want reconstruction, what type is best for you? Should you have gene testing? Our breast cancer app can help with these questions and much more.
The groundbreaking Breast Advocate® Wizard walks users through a detailed questionnaire to better understand their personal situation, preferences and goals. Our proprietary software combines evidence-based treatment options with the user’s preferences to create customized recommendations that are in line with the user’s specific needs. Breast Advocate® empowers users with the knowledge they need to fully discuss their treatment plan with their medical team and ensure they make the best decisions for them.
Users also have access to the latest expert opinions, published studies, helpful resources, and a community ready to provide support.
Download the latest version of the Breast Advocate app here.
Does DIEP flap breast reconstruction increase the risk of breast cancer recurrence?
Patients choosing to undergo breast reconstruction are often concerned that their decision may increase their risk of breast cancer recurrence. A recent study published in the British Journal of Surgery looked at the risk of recurrence specifically after DIEP flap reconstruction.
The study compared 250 patients who had DIEP flap reconstruction between 1999 and 2013 with more than 700 control patients. Breast cancer recurrence was seen in over 19 percent of patients who had DIEP flap surgery and over 23 percent of patients in the control group. Interestingly, the 5-year breast cancer-specific survival rate was highest in patients having DIEP flap surgery after 2008 – 92.4 percent in the DIEP flap group versus 87.4 percent in the control group.
The study design does raise some questions about selection bias. For example, all DIEP flap procedures in this study were performed at least 24 months after mastectomy. No DIEP flaps were performed at the same time as the mastectomy (‘immediate’ reconstruction). In addition, a larger number of patients in the DIEP flap group than the control group received adjuvant therapy.
While the survival rates between groups may have been influenced by patient selection, this study shows that patients with breast cancer undergoing DIEP flap breast reconstruction do NOT have a higher rate of breast cancer recurrence than patients undergoing mastectomy alone.
New Approach to Breast Reconstruction May Reduce Pain and Weakness for Some
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.
