Low uptake to rebuild breast

12
THE STRAITS TIMES
MAY 15 2014
Cover Story
Low uptake to
rebuild breast
Immediate breast reconstruction after breast
cancer surgery can restore a woman’s body
image and is psychologically beneficial. Yet
not many women here opt for it
NG WAN CHING
W
hen Ms Kathy Chioh found
out she had breast cancer
around the age of 40, she
had no doubt she would
want her breast
reconstructed after the
tumour was removed.
After discussing it with her breast
surgeon and plastic surgeon, she decided to
have a fairly new procedure, which used fat
from her thigh to partially reconstruct her
breast, as even breast conserving surgery
would leave a deformity.
The procedure usually takes fat from only
one thigh as it would yield enough to
reconstruct a breast.
Her plastic surgeon, Dr Evan Woo, who
runs the Evan Woo Plastic Surgery Clinic at
Mount Elizabeth Novena Medical Centre,
said that the resulting asymmetry between
the thighs would not be that perceptible
when she is wearing clothes.
If there is asymmetry that patients are
not happy with, touch-ups could be done
during the nipple reconstruction stage a few
months later.
One of the considerations for the slim
and petite 42-year-old housewife was to
preserve her tummy tissue in the
unfortunate event that cancer strikes again
in either of her breasts, even if her risk of
recurrence was not high.
Another patient, Ms Juliana Lok, 40, was
diagnosed with breast cancer when she was
38. At that point, she had been trying for a
baby for a few years and had adopted a
baby girl.
She chose to have breast reconstruction
immediately after her mastectomy, which is
the surgical removal of one or both breasts.
As she was still hoping to have a child
after her cancer treatment, her surgeon
avoided using her tummy tissue to rebuild
her breast, as this would weaken her
abdominal wall muscles. Tissue from her
thigh was used instead.
But Ms Chioh and Ms Lok are among the
minority here. Despite an increasing array of
surgical methods in breast reconstruction
for women in many different circumstances,
few actually choose it.
There are some 1,400 new cases of
breast cancer a year in Singapore, yet
doctors say fewer than three in 10 women
choose to rebuild their breasts.
A 10-year review at Singapore General
Hospital (SGH) found that only 448 patients
had breast reconstruction after cancer
between January 2001 and December
2010, out of about 7,000 cases of breast
cancer over the period.
Over at KK Women’s and Children’s
Hospital (KKH), about a quarter of patients
who had their breasts removed due to
cancer opted for reconstruction in the last
five years (2009 to 2013).
KKH performs about 250 operations a
year for breast cancer, said Dr Lim Swee Ho,
the acting head and consultant at the
hospital’s breast department.
At National University Hospital, doctors
estimate that about 35 per cent of the 400
women who undergo breast cancer surgery
each year choose to have breast
reconstruction, said Dr Chan Ching Wan, a
senior consultant at the division of general
surgery (breast surgery).
Overall, studies have found that, for a
variety of reasons, Asians tend to be less
likely to undergo breast reconstruction than
Caucasians, said Dr Christopher Chui, an
associate consultant at the department of
plastic, reconstruction and aesthetic surgery
at SGH.
INCREASING PATIENT AWARENESS
Here, doctors are trying to increase patients’
awareness of their options through a fairly
new group called Breast Reconstruction
Awareness Singapore, said Dr Chui.
The society, launched in October, aims to
provide women with relevant information so
they can make an informed decision.
Studies done in the United States, Britain
and Australia show that women choose not
to have breast reconstruction due to
reasons such as advanced age at the time
of the mastectomy, concerns about
complications from further surgery and
uncertainty about the outcome, said Dr Chui.
Some have mistaken fears that the
reconstruction can cause the cancer to
return or mask a recurrence.
And there are others who believe the
procedure is not essential for one’s physical
or emotional well-being, or they do not want
anything unnatural in the body.
Here, doctors say many women are
understandably more concerned about the
prognosis of their cancer than the physical
PHOTO: NG WAN CHING
Ms Juliana Lok, seen here with plastic surgeon Evan Woo, chose to have breast reconstruction
immediately after her mastectomy. Tissue from her thigh was used instead of that from the tummy
to avoid weakening her abdominal wall muscles as she was planning to have a baby.
ILLUSTRATION: NEW YORK TIMES
changes that would arise from surgery, and
prefer treatment that would be the simplest
and most straightforward, said Dr Benita
Tan, a senior consultant in the department
of general surgery at SGH.
Many were not keen on breast
reconstruction surgery as this may involve
taking tissue from other parts of the body,
she said.
It would mean more surgery, as well as
longer hospital stays and post-operative
recovery, she added.
Another reason is that Singapore still has
a fair number of women who discover their
breast cancer at a later stage, said Dr Tan.
Data from the National Disease Registry
Office (NDRO) shows that only about 40 per
cent of breast cancer cases are in the very
early stages – stage 0 and stage 1 –
compared with higher numbers in the US,
Britain and some Asian countries such as
South Korea.
This results in a shift in the priorities of
both patients and doctors caring for patients
with advanced disease, with reconstruction
taking a back seat while they hasten
chemotherapy and other treatments such as
radiotherapy.
Women with non-invasive and early stage
tumours get to the stage of considering
reconstructive surgery more quickly, as they
may not need chemotherapy or radiotherapy
after the mastectomy.
“If we are able to diagnose the cancer
earlier, more women may be receptive to
breast reconstruction and benefit from it,”
said Dr Tan.
This would be possible only if there is a
better awareness of breast cancer,
treatment options and prognosis, as well as
increased participation in breast cancer
screening, she added.
AGE MATTERS
Age is another factor for the low rates of
reconstruction here, as women who get
breast cancer here are older.
If a woman is over 50 by the time she is
diagnosed, it is less likely that she would
want breast reconstruction, said Dr Chui.
Major reasons given for not having
reconstruction include fear of complications
and perceiving themselves as being too old
for the procedure, he added.
Data from the NDRO shows that only
20 per cent of the women here with breast
cancer are under 40 years old.
It is known that younger patients may be
more concerned with their appearance after
surgery, body image and sexuality.
Therefore, they are more likely to want
breast reconstruction, said Dr Tan.
They may generally be in better health as
well, making them more likely candidates to
be considered for reconstructive surgery.
In the 10-year review of women treated at
SGH, those who opted for breast
reconstruction were on average 46 years
old, although the median (most common)
age range of the entire group was 50 to 59
years, said Dr Tan.
“Our older patients tend to cite that they
are already old and there is no function or
need for the breast and do not want to
consider breast reconstruction,” she said,
adding that there is an ongoing study to
analyse this issue.
The truth is, age is no barrier for breast
reconstruction. The oldest patient to do so
at SGH was 70 years old.
“She did very well and benefited from the
surgery. It is also important to note that
women are living longer and the peak age
group for breast cancer is now 60 to 69
years (based on data from 2008 to 2012)
and we could expect more older women to
opt for breast reconstruction in the future,”
said Dr Tan.
Still, however slowly, awareness has
grown over the years.
The proportion of patients undergoing
reconstruction increased from 5.9 per cent
in 2001 to 15.7 per cent in 2010 at SGH,
said Dr Tan.
It is the same at NUH, now that patients
are more informed and doctors have a better
understanding of tumour biology and use
safer modern techniques, procedures and
anaesthesia, said Dr Jane Lim, a senior
consultant at the NUH Aesthetic Plastic
Surgery Centre.
As a result, women are coming to accept
breast reconstruction after a mastectomy.
It is a trend that surgeons, such as
Dr Woo, hope will continue.
“An often overlooked aspect of treating
breast cancer is the psychosocial aspect of
the disease process and its treatment,”
said Dr Woo, who is also a consultant in the
department of plastic reconstructive and
aesthetic surgery at KKH.
Losing one or both breasts not only
leaves a patient with physical scars but also
has a significant psychological impact, said
Dr Woo.
The loss can be traumatic and have a
negative impact on a woman’s body image
and sexuality.
RECONSTRUCTION BENEFITS
Immediate breast reconstruction can restore
a woman’s body image and is
psychologically beneficial.
Studies have reported improved overall
satisfaction, body image, self-esteem,
feelings of attractiveness, and decreased
anxiety and depression in patients who have
immediate reconstruction compared with
patients who delay it, said Dr Chui.
The benefits outweigh any problems and
few patients express any regret at having
undergone breast reconstruction.
Studies have also shown that those who
have had their breasts reconstructed have a
quality of life as well as social and sexual
relationships that are not significantly
different than those of healthy women, he
said.
Furthermore, restoring breast symmetry is
not just for aesthetics alone.
It gives the woman the ability, comfort
and convenience of wearing clothes
normally, without a need to put on a
prosthesis and to have body balance in back
care, especially for women who have larger
breasts, said Dr Tan.
It is also important for women to
recognise that breast cancer does not mean
having to lose the breast, she added.
Treatment could be a combination of
surgery, chemotherapy, radiotherapy,
hormonal therapy and targeted therapy
(molecular drugs) that is individually tailored
to the patient’s condition.
Women with small, single tumours could
be suitable for breast conservation surgery,
depending on the nature of the disease.
With good techniques, this would result in
only slight changes to the breast, allowing
women to keep their breasts without
significant deformity, said Dr Tan.
These days, even women with slightly
larger tumours may still be able to save their
breasts using newer techniques, said
Dr Tan.
Reconstructive surgery is particularly
valuable among Asian women, who tend to
have smaller breasts. There is almost
certainly a deformity if no corrective surgery
is done even after a lumpectomy (breast
lump removal), said Dr Woo.
All patients should be offered the option
of breast reconstruction, said Dr Graeme
Perks, president of the British Association of
Plastic Surgeons who was in Singapore last
week for the Royal Australasian College of
Surgeons meeting.
In Britain, there are guidelines to
recommend reconstruction to all patients
undergoing a mastectomy, he said.
“I think we should have similar guidelines
here and this needs collaboration between
the breast and plastic surgeons,” said
Dr Woo.
Both Ms Chioh and Ms Lok have no
regrets about choosing reconstruction.
“I thought I would have a hole in my
breast after surgery to remove the cancer.
But my breast looks normal and the scars
are minimal,” said Ms Chioh, a housewife
with a 21-year-old daughter.
Meanwhile, Ms Lok has decided to stop
trying for a baby. Her adopted baby girl is
now 18 months old. The former air
stewardess said she would not have done
anything differently.
She said: “I was very happy when the
surgeon offered me the option of having a
reconstructed breast using my own tissue. I
did not like the idea of a breast implant.
“Now, I feel normal again.”
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Pros and cons of breast reconstruction,
Page 14
14
THE STRAITS TIMES
MAY 15 2014
Pros and cons of breast reconstruction
T
he latest innovations for
breast reconstruction
involve transferring the
patient’s own tissue from
the tummy, buttocks, thigh
or back, said Dr Evan Woo,
a consultant at the department of
plastic, reconstructive and aesthetic
surgery at KK Women’s and
Children’s Hospital.
Surgeons then have to take only
the skin and subcutaneous fat from
another part of the body to
reconstruct the excised part.
Using the patient’s own tissues to
reconstruct the breast results in an
outcome that looks and feels the
most natural, said Dr Woo, who also
runs the Evan Woo Plastic Surgery
Clinic at Mount Elizabeth Novena
Medical Centre.
The breast will grow and age with
her. It gets bigger when she puts on
weight and smaller when she loses
weight, he added.
The lower abdomen is the most
common source for reconstructing
the breast.
A plastic surgeon can contour the
body, ridding it of unwanted skin and
fat and purifying it to rebuild the
breast. The patient benefits from a
tummy tuck at the same time.
Some possible complications
include weakness of the abdominal
wall after the surgery, if part or the
whole of the central abdominal
muscle has to be sacrificed.
This is because even when
surgeons try to spare as much
muscle as possible, they are still
dissecting through the muscle to get
a length of a blood vessel which
supplies the skin and fat.
“If it doesn’t heal properly, the
patient can get weakness there,”
explained Dr Woo.
Weakness in the abdominal wall is
manifested as a slight bulge of the
tummy.
In very rare cases, if the weakness
is severe, the bulge can be large
enough to contain some parts of the
bowel. This is known as a hernia.
However, the weakness and the
hernia can usually be repaired with
minor surgery, said Dr Woo.
One of the newest methods for
reconstructing the breast is the
transverse upper gracilis (TUG) flap.
In this procedure, the gracilis
muscle in the inner thigh and its
blood vessels are taken together with
the overlying skin and fat and
transferred into the breast pocket.
The blood supply to the gracilis
muscle and the overlying skin is then
reconnected to keep it alive.
This requires microsurgery
expertise, typically to connect the
blood vessels in the chest with those
from the gracilis muscle.
GOOD CANDIDATES
Women who have smaller breasts (A
or B cup) with some excess fat in the
inner thighs are good candidates for
this procedure. There is also the
benefit of lifting and tightening the
inner thigh.
Anyone without enough tissue in
the inner thigh or who previously had
a thigh lift or liposuction at the inner
thigh is not suitable.
Because of the microsurgery
techniques, this procedure can take
six to eight hours to complete,
compared with around three to five
hours for the other methods.
There is also a small risk of failure
when re-establishing blood flow to
the gracilis flap.
Breast reconstruction can be
partly paid for with Medisave and
some insurance plans cover it.
Having a mastectomy and
reconstruction done together means
less general anaesthesia used and a
shorter recovery period, reducing the
length of stay in the hospital and
medical costs, said Dr Woo.
Reconstruction is also easier as
the skin which covers the breast
(skin envelope) and the
infra-mammary fold (lower border of
the breast) are preserved, and the
surgeon can mould a new breast into
this skin envelope, said Dr Woo.
The patient also need not go
through the experience of being
“breast-less” and will be able to wear
the same bra and clothes.
However, having two operations
together will result in a longer
operating time, sad Dr Woo.
In any case, breast reconstruction
can be performed much later as well,
after additional cancer treatment
such as chemotherapy or
radiotherapy has been completed.
Ng Wan Ching

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