Doctors at the Aga Khan University Hospital in Nairobi recently performed two novel surgeries – nipple sparing mastectomy and skin sparing mastectomy – which allowed them to remove breast cancer from a patient, while preserving the breast’s skin envelope and nipple, and then reconstructing the breast that was removed using tissue from the abdomen. This writer, a breast surgeon, who was part of the four-doctor team involved in the process shares what this means for breast cancer patients.
Every year, about 8,000 people are diagnosed with breast cancer, a cancer that is curable and has very good overall survival if detected early and treated appropriately. The mainstay of treatment for early breast cancers is surgery. In early cancers, surgery could involve either a breast conservation surgery or a ‘lumpectomy’, where one removes just the lump with a margin of normal tissue, or a ‘mastectomy’, where the entire breast is removed. Not all patients are suitable to have breast conservation for various reasons. Sometimes, even with an early cancer or what is described as a ‘pre-cancer’ (changes in the breast tissue that will progress in time to cancer), the safer surgery needed to remove all the cancerous changes seen is a mastectomy. However, breast cancer surgery is associated with the highest rate of psychological consequences for patients.
This frequently has to do with the perceptions of self and body image after the loss of a breast through a mastectomy. Conversely, studies show an overwhelming benefit in terms of quality of life and lower incidences of depression in patients who have had breast conservation or reconstruction. Bringing it closer home, our local research into the reasons why breast cancer patients are diagnosed at an advanced stage, show that in addition to financial and health system factors, there is still a lot of stigma around breast cancer. Even worse, family disintegration following a diagnosis of breast cancer is not infrequent. What was really thought provoking though, was that this disintegration occurred irrespective of the socio-economic status and levels of education of patients and their partners suggesting that more fundamental reasons like socio-cultural constructs may play a role.
Women could potentially lose their homes or livelihoods after a diagnosis of breast cancer. While many families and spouses/partners are largely supportive, they are occasionally are not. The fear of mastectomy, and its downstream sociocultural effects may be one of the significant reasons why women do not seek help early. Ready access to breast conservation and reconstructive services could perhaps help to change the discourse around this situation.
A frequently overlooked aspect of overall cancer care is the reconstructive services required. Reconstruction simply put refers to a ‘return to former function’. While cancer surgery aims at removing the tumorous growth, the aim of reconstructive surgery is to replace or restore that which has been removed in order to successfully return an individual to their previous performance.
Patients with early cancer can undergo a mastectomy and have an immediate reconstruction where a definitive new breast is created¸ while those with more advanced cancers who are likely to have other treatments such as radiotherapy will sometimes have a staged reconstruction. It is also possible to have reconstruction done after your primary cancer surgery and this is known as a delayed reconstruction.
The main types of reconstruction are implant-based reconstructions where a bag of saline or silicone is used to create a new mound or through using one’s own body tissue (autologous reconstruction). Implant-based reconstruction involves placing an implant either over or under the chest muscle. It may be suitable particularly when bilateral surgery is required or when patients cannot withstand a long operating time. The reconstruction could be immediate or staged where a balloon like envelope is placed under the skin after the initial surgery and slowly expanded over time to stretch the skin. A second surgery is then performed to insert a permanent implant.
Implant-based reconstructions are generally safe, but may require an additional number of procedures. The disadvantages are that as a foreign body, it can sometimes provoke a reaction in the body with resultant healing by scaring resulting in thick scar tissue around the implant called a contracture resulting in a firm mass on the chest wall. This may modify the feel and appearance and one patient who developed this, described it as having a ‘golf ball on one’s chest’. It is however a quick and less complex procedure with shorter hospital stays and a quicker return to function.
The challenges of a single side (unilateral) implant are that to achieve a balanced aesthetic outcome, one may need to do additional surgery to match the new breast. This is known as a symmetrising procedure and may involve a breast reduction or other procedures. The implant does not age like the normal breast tissue on the other side, and as the irresistible pull of gravity causes an invariable gentle drift of all things downwards in time,(be they tummies, spines or knees), the only structure resisting this pull might be the implant! As a result, one might in time, if so desired, have surgery to the opposite breast to address this discrepancy.
Autologous reconstruction means reconstruction done using one’s own body tissues. This type of reconstruction is more complex and may involve removing the skin, fat and sometimes muscle from one body part and transplanting it to a different area. This tissue is frequently from the back or abdomen. The portion of tissue that is taken from a different area with its blood supply is known as a ‘flap’.
Autologous flaps may be suitable if one needs to have radiotherapy as part of one’s subsequent treatment, if one has larger breasts and does not wish to have a reduction in size after the surgery, or if one prefers not to have, or is an unsuitable candidate for an implant reconstruction. These operations are lengthy but seldom require additional surgery. This operation gives a more natural shape and feel to the breast. In addition, the tissue ages with the breast so it is easier to have long-term symmetry. The disadvantage is that one has a scar along a different body part where the tissue is harvested and there is a longer hospital stay and recovery time from this procedure.
Newer novel techniques also exist where fat from the abdomen is harvested and used to reconstruct a new breast. This process is known as lipo-filling and may require several procedures to build this up sequentially to the desired breast size. All this options are available locally, but require an in-depth discussion with the surgeon, discussing the pros and cons and suitability of the different techniques for the individual. This needs to be performed in concert with the multi-disciplinary team discussion so that the most appropriate treatment and surgical strategy is agreed upon.
After careful counsel and discussion, two patients were able to successfully undergo reconstruction – their breast cancer was first removed and new breast mounds were fashioned. In the room were reconstructive surgeons Dr Radovan Boca (lead reconstructive) and Dr Tillman Stasch, anaesthetis, Dr Lilian Lukoko and breast surgeon Dr Miriam Mutebi. After removal of the breast cancer, tissue from the abdomen was harvested with its blood vessels and then transplanted onto vessels on the chest wall to create a new breast mound (free perforator flap) so that the patient went to sleep with a breast, had her cancer removed, and woke up with a new breast, in what is described as an ‘immediate reconstruction’. This complex reconstruction, known as a deep inferior epigastric perforator flap (or DIEP flap....a long moniker based on the name of the blood vessels that it is based on!) requires meticulous reimplantation of blood vessels from the abdomen to the chest using a microscope (microsurgery).
Unfortunately, for many ladies these options have been largely inaccessible for a number of reasons. While these procedures for breast cancer continue to be the standard of care for breast cancers internationally, a critical stumbling block has been the perception of breast reconstruction by healthcare payers as a ‘cosmetic’ procedure. As a result, many insurances locally would traditionally reject claims and patients would frequently have to pay out of pocket for these services. As the costs are frequently prohibitive, many patients then would abandon their hope of receiving a reconstruction.
Luckily, there is growing awareness and education of our populations alongside a better understanding of the role of reconstructive services in surgical care. The tide is thankfully, slowly turning and insurances are becoming more receptive to bearing the costs for these services, but more efforts need to be made. As the local skill set increases and as we start to develop the argument for universal care and access, it is important to develop reconstructive services in tandem with other surgical services and to expand intervention strategies that help to diagnose and treat women with earlier disease.
It is important to frame this argument through the lens of health economics and urge both the government and private funding bodies to consider development and financial support for reconstructive support as a health investment or dividend rather than an expenditure. A well-adjusted individual who is able to return to their previous functional status is able to work as a productive member of society.
Developing reconstructive services also has a ‘Trojan horse’ effect that benefits not just breast cancer and other cancers, but could potentially spread to other aspects of healthcare. One such arena that comes to mind is in trauma, where our hospitals frequently have dedicated ‘bodaboda’ wards, as a result of multiple road traffic accidents. These accidents frequently result in loss of limbs that are frequently life-changing in our environment, more so due to a paucity of supportive rehabilitation services. A previously self-sufficient, 22-year-old young man is forced to rely on support of family as he may no longer able to walk to work or spend a day working on the ‘shamba’. He may also not be able to raise enough funds to access rehabilitative services or to acquire a prosthesis. Suppose, we said that instead of losing the limb, we could harness these very same techniques to do ‘limb salvage’ surgery and retain the function of that leg or arm? Cost to this individual? Priceless!
We do, however, appreciate that our resources may not be infinite and we definitely need to address the current cost of reconstructive services. Indeed advocacy for these services must continue on all fronts. As we currently do not manufacture many of the materials or devices used for reconstruction, excising large duties on these imports, only serves to broaden existing disparities and make these services even less accessible. The onus is on all of us collectively push for changes around this. It is the anticipation that through these, and other ongoing efforts we can start to change the narrative around breast cancer and reduce the stigma and fear of losing a breast, not just for women but for the communities they need to be reintegrated into.
Dr Mutebi is a breast surgeon at the Aga Khan University Hospital in Nairobi