New York Times Examines Reconstructive Surgery Options For Women With Breast Cancer

Main Category: Breast Cancer
Also Included In: Cosmetic Medicine / Plastic Surgery
Article Date: 24 Dec 2008 - 3:00 PDT

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The New York Times on Tuesday examined reconstructive breast surgery options provided to cancer patients undergoing mastectomies. According to the Times, despite recent advances in reconstructive breast surgery procedures, many plastic surgeons fail to inform women about the extent of their options. Some surgeons might not be trained to perform the latest operations, and others lack incentives to promote surgeries that are less profitable for physicians and hospitals, the Times reports. Diana Zuckerman, president of the National Research Center for Women and Families, said, "It is clear that many reconstruction patients are not being given the full picture of their options."

According to estimates from the American Society of Plastic Surgeons, about 66,000 women in the U.S. had mastectomies in 2006, and about 57,000 women had reconstructive breast surgery in 2007. Implant surgery, which initially involves the least surgery and shortest recovery time, is the most popular breast reconstructive method in the U.S., but implants also can lead to future complications and additional surgeries. Newer procedures, called flaps, generally involve transplanting a wedge of fat tissue and blood vessels from the abdomen or buttocks and reforming them into new breasts. The most common flap procedure, called a TRAM flap, uses abdominal fat and muscle containing blood vessels to rebuild the breast. Although this procedure carries a risk of a weakened abdominal wall or hernia, a newer technique, called the DIEP free flap, does not use muscle and might reduce the likelihood of abdominal problems. However, researchers have not conducted rigorous studies or established complication rates for the flap procedures, Amy Alderman, assistant professor of plastic surgery at the University of Michigan Medical School, said. Scott Spear, chief of plastic surgery at Georgetown University Hospital, said all breast reconstructions involve a trade off. "The implants have a lower investment in the short term and a longer-term higher risk of having to redo it," he said, adding, "The flaps have a bigger investment in the short run, but you are less likely to revise it in the long run."

According to the Times, many physicians neglect to inform women about the newer breast reconstruction methods because the physicians might not be proficient in the required techniques. Stephen Colen, chair of plastic surgery at Hackensack University Medical Center, said, "A lot of patients are offered implants because the surgeon does not know how to do the flap, and then the implant fails and they need the flap anyway." In addition, some surgeons may not inform patients about the flap procedures because implant surgery can be more profitable. According to the Times, a typical Manhattan surgeon charges insurance companies $7,000 for a one-hour implant reconstruction surgery, but would charge $15,500 for a DIEP procedure lasting six to 12 hours. Spear said that although it is "embarrassing to say so," when surgeons examine insurance reimbursements, the flap procedures are seen as "a loss leader" because they require substantial time and effort for a relatively lower cost. In addition, flap surgeries sometimes require higher copayments for patients than implant surgeries. Richard D'Amico, former president of ASPS, said low reimbursements for flap surgeries are a "disincentive for plastic surgeons even to do the work."

According to Alderman, some physicians do not discuss any breast reconstruction methods with patients undergoing mastectomies. According to a study led by Alderman and published in February in the journal Cancer, only one-third of women undergoing surgeries for breast cancer said their general surgeons had discussed reconstruction at all. "In the big picture, it would be great if we could just get doctors to tell people they have an option of reconstruction," Alderman said. To raise awareness of the issue, ASPS has "adopted the vocabulary of the movement to support a woman's freedom to choose abortion, adjusting it to women with breast cancer," the Times reports. Plastic surgeon Linda Phillips during an October telephone news conference to mark Breast Cancer Awareness Month said that although women "don't choose their diagnosis, they can choose what their options might be. Then they have that much more power over their lives if they have that power to choose." Robert Allen, a Manhattan-based plastic surgeon who developed the DIEP flap, recommended that patients discuss breast reconstruction surgery with women who have undergone successful operations and others who have experienced later complications. "Patients should not necessarily accept the first thing they hear as the end-all, because that is not necessarily the full story," Allen said (Singer, New York Times, 12/23).

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