Gary M. Freedman, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: April 3, 2013
When women are diagnosed with breast cancer, they are immediately faced with an overwhelming amount of information and a need to make important decisions regarding treatment. The most important thing that must be decided on with their team of oncologists is how to best treat the cancer and reduce their risk of a recurrence or spread. However, another important issue to consider is the cosmetic outcome of the treatments. There have been studies that show that the final cosmetic outcome of a women's procedure for breast cancer therapy will greatly influence their quality of life. One of the questions that frequently comes up among patients and doctors is how to best time the different therapies that are going to be administered: both for optimal management of the cancer and for creating an excellent cosmetic result.
Radiation therapy is an important part of the modern multimodality treatment of breast cancer. While radiation for women who have had lumpectomy, or a part of the breast removed, has been a routine part of treatment for many women for decades, radiation has had an increasing role in the treatment of patients who are at risk for recurrence after mastectomy. Large and well-designed clinical trials have shown that some women who have had mastectomy may benefit from radiation to the chest wall and axillary (armpit) area after the breast is removed. Women most likely to be recommended radiation after a mastectomy are those with large tumor sizes, axillary lymph nodes that are found to have cancer in them, or close surgical resection margins. The decision of whether to pursue radiation after mastectomy is very individual, and should only be made after consultation with a radiation oncologist.
In recent decades, there has also been a shift to a less extensive surgical approach to mastectomy, which allows reconstruction of the breast after it is removed. In the past, reconstruction was not possible after mastectomy, because the muscles of the chest wall were removed. Now, more modern techniques allow many of the muscles to be left in place when the breast is removed. These muscles are important for the reconstruction to be performed. Some mastectomy techniques even allow the breast skin to remain. These changes have made reconstruction of the breast possible for most women.
Once a decision has been made that a woman is a candidate for both breast reconstruction and radiation therapy, there are several options for management that include timing of reconstruction and surgery, timing of reconstruction and chemotherapy, timing of reconstruction and radiation, and the type of reconstruction. These decisions are best made by a team approach of the patient’s surgeon, plastic surgeon, medical and radiation oncologists.
Once a decision has been made between a patient and the plastic surgeon for breast reconstruction, one of the first decisions to be made is regarding either immediate (at the time of mastectomy) or delayed (after mastectomy) reconstruction. Most patients are eligible for immediate breast reconstruction.
Delayed breast reconstruction refers to reconstruction of the breast after completion of mastectomy and all chemotherapy and/or radiation therapy. Some physicians feel that delayed reconstruction may help a patient receive the chemotherapy and radiation she needs more efficiently and with fewer risks of side effects than she might develop if the reconstruction were done right away; however, with modern approaches to radiation and chemotherapy delivery, most physicians no longer have these concerns. Modern radiation equipment, which incorporates CT scan three-dimensional planning and computer modeling in virtual reality, allows sophisticated treatment plans to be developed for most patients with or without a reconstructed breast. Another reason for delaying reconstruction may include patient preference because she is not certain she wants reconstruction at all, or if she is medically not a good candidate for the procedure. In some cases, there may be a concern that scheduling and recovering from reconstruction could introduce an unacceptable delay between mastectomy and chemotherapy. This fear may be greater for a patient with locally advanced breast cancer than one with early stage breast cancer. Delaying reconstruction until after completion of all adjuvant chemotherapy and radiation does have some potential downsides: It may mean a patient waiting 6-9 months for the procedure - which may be unacceptable to some women. In addition, delayed reconstruction requires that a patient undergo a second major operation. Finally, delayed reconstruction may be more difficult for patients who require a breast implant for their reconstruction. Because decisions regarding delaying reconstruction are so complicated and individualized, they should be discussed carefully with a plastic surgeon.
Immediate timing of reconstruction, when the breast is reconstructed during the mastectomy, will provide the patient with an important cosmetic and psychological benefit - not awaking from mastectomy with a complete absence of a breast. Immediate reconstruction is also associated with avoidance of a second major operation, since both the mastectomy and reconstruction of the breast are done at the same time. Again, the decision of whether to pursue immediate or delayed reconstruction is complicated, and should be discussed with the treatment team before the mastectomy is performed. Having some more information regarding types of reconstruction may be helpful, and these details are discussed below.
Many women will require a breast implant to be placed in order for the breast to be reconstructed. Breast implants now come in a variety of forms, shapes and material. While for a period of time only saline implants were available, silicone implants are now available for many women and may have advantages in cosmetic results and lower complication rates, particularly when radiation is required. Patients having immediate reconstruction by implant most commonly are treated with a two-stage technique. The first stage involves placing a tissue expander, which is similar to a balloon, under the skin and chest wall muscles at the time of mastectomy. The balloon expander is filled over time to expand the implant and in turn stretch the skin slowly and prepare it for placement of the implant. In the second stage, the expander is removed and replaced with a permanent implant. This second stage may be done either before or after any planned radiation therapy depending on the preference of the plastic surgeon.
Complications of breast reconstruction with implants include infection, hardness, changes in size or shape of the breast, dimples or rippling of the implant, and changes in symmetry with the opposite breast. Radiation is most commonly associated with hardness or asymmetry with the opposite breast. As radiation may make the skin and muscles of the chest less elastic, the implant may be squeezed within its pocket beneath the muscle into a position higher than the other breast. These risks may be reduced by arm and chest muscle stretching, range of motion exercises, regular lotioning of the skin, and massaging of the implant in the first months after radiation. In some cases, the implant can be revised surgically or exchanged to improve the symmetry or overall cosmetic result. The implant may rarely need to be removed altogether because of radiation-related complications.
Autologous tissue reconstruction refers to the use of the patient’s own tissue rather than a foreign body implant to reconstruct the breast. This may involve creating a breast using tissue from the abdominal skin, subcutaneous fat and muscle. The procedures are named for the muscle used, including: TRAM (transverse rectus abdominis myocutaneous), DIEP (deep inferior epigastric perforator), SIEA (Superficial Inferior Epigastric Artery), buttock (gluteal) or back (lattisimus). Autologous muscle transfer is generally felt to have a lower risk, or less serious risks, with radiation therapy than implants. The trade off is that the operations for tissue transfer are generally longer and more extensive than those for implants. Some women are not candidates for tissue transfers if they do not have enough fat associated with their skin and muscles to build a breast the size of the healthy breast, or have history of prior abdominal operations.
Complications of breast reconstruction with tissue transfers may include delayed wound healing, insufficient blood supply to parts of the reconstruction that affect healing or cosmetic results, infection, or fat necrosis (small hard nodules of fat inside the breast). There may also be complications related to the site the tissue is donated from - such as delayed healing of lower abdominal wounds. Radiation is most commonly associated with changes in overall size of the reconstructed breast creating asymmetry with the opposite breast, or fat necrosis. Unlike implants, complete loss of an autologous reconstruction from radiation does not occur.
The greatest advance leading to the overall increased use and success of breast reconstruction has been the multidisciplinary approach to the management of patients with breast reconstruction. It is essential for a patient to have a team of a plastic surgeon, and radiation, surgical and medical oncologists working together to make the best individualized decisions for that particular patient’s preferences, anatomy, and cancer-specific treatments. Newer techniques of radiation therapy, improved patient selection and coordination between the multidisciplinary team for the type and timing of reconstruction, has created the promise of low complication rates and good or excellent cosmetic results for most patients with modern breast reconstruction.
The decisions regarding the timing and type of reconstruction, and the timing of radiation, must be made on an individual basis. However, this article can help you better understand the options available to you and the considerations surrounding each.