Breast Reconstruction: the Right to Choose?

The May issue of Cancer cites a study that showed the vast majority of breast cancer surgeons do not offer reconstruction surgery to women who must have a mastectomy. I learned this during an interview this morning with Dr. Kara Kort for my radio show. (It will air May 2.)

The study also said the vast majority of women don’t have reconstruction surgery after their mastectomies. Based on the findings of the study — I have to ask — why? Because they don’t want it? Or because they don’t know it’s an option?

To be clear — I have not had breast cancer. Too many friends have, but not all have had mastectomies, and of them, only one or two have had reconstruction surgery. But I offer the following train of thought — my understanding, my questions, and my suggestions for women who must have mastectomies.

A woman finds a lump (or a lump is found) and is referred to a surgeon for a biopsy and subsequently, the woman and her surgeon develop a treatment plan. Typically the surgery takes place, then perhaps radiation or chemo. The standard of care and most usual scenario, according to Dr. Kort, is that the reconstructive surgery (to rebuild her breast to return her shape close to its state before the surgery), happens right away during the removal surgery, as soon as the cancer has been removed from her body. (There are exceptions.) That means, she does not usually have to wait to return for more surgery — it’s all taken care of right then and there.

Two surgeons are involved. The one who removes the breast and cancerous tissue, and a plastic surgeon.

My questions:

What about insurance? I learned that by federal law enacted in 1998, , health insurance carriers that cover mastectomies must also pay for breast reconstruction. Of course, that doesn’t help women who don’t have insurance coverage to begin with, nor does it cover many state-issued insurances such as medicaid in New York State (where I live.) But it certainly helps those who do have coverage.

Why don’t doctors provide reconstruction as an option? Dr. Kort seems to think most of them are leaping to their own conclusions as to whether a woman will be interested. Dr. Kort told me she offers reconstruction to all her patients, and in the past, has been very surprised by those women who choose to have it, vs those do not. Age does not seem to be a factor at all, and she gave the example of an 80-year-old woman who insisted on recontruction vs a 35 year-old mother of three young children who just didn’t care about it.

A second reason they don’t offer the option is cost. Despite the fact that insurance covers it for many, there are too many plastic surgeons who don’t want to deal with too-low reimbursements. If they have their choice between a cash deal for a facelift, and a paperwork-laden low reimbursement for breast reconstruction — well — let’s see…. (don’t forget: American Healthcare is not about health or care; it’s about sickness and money.)

And then there was my question about sexism: do we have any studies on the number of male surgeons who offer reconstruction vs female surgeons who offer reconstruction? No. Of course not. I’m make a leap here and suggest that the female surgeons are far more likely to offer reconstruction.

As Every Patient’s Advocate, here’s my bottom line for ALL women facing mastectomy:
You have the RIGHT TO CHOOSE: reconstruction or no reconstruction. When surgeons are providing treatment options and developing treatment plans for you, the possibility of reconstruction should ALWAYS be discussed.

If you are a woman, or love a woman who faces a mastectomy, make it a point to ASK YOUR SURGEON about reconstruction, and learn what you can about it before you decide whether or not you want it. Also, be sure to get a SECOND OPINION, regardless of whether or not you “like” or trust your first surgeon. You can always return to the first opinion doctor, but you need two opinions so you can learn even more. We’re talking about your LIFE. It’s worth the trouble to get a second opinion.

And — ask other women who have experienced mastectomies for their opinions. Ask one breast cancer survivor, and she will lead you to more — some who have had reconstruction, and others who have not. Listen to what they tell you about their own experiences, then judge for yourself.

As Every Patient’s Advocate, here’s my bottom line for ALL surgeons who perform mastectomies:
Your job requires you to offer all treatment options, whether you think they are the right choice or not. Further, you need to stick to your surgery and stop trying to read minds. Don’t try to figure out if a patient will want reconstruction. Offer it to her, and let HER decide.

If you or a loved one have experienced breast cancer and want to weigh in — please do! I’d love to hear from you.

And someday, when I’m looking for something to write about, I’ll tell you about my friend who not only had reconstruction, but had nipples tattooed on her new breasts, too. Now THAT’s a choice to live life to the fullest!

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Trisha Torrey
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