Devra (left) and Leslie were paired as college roommates more than 30 years ago. Today, Devra participates in the Avon Walk, not only to raise money for a cure, but to stay connected to her lifelong friend.

Nearly 2,000 of us gathered at the foot of the Washington Monument on an early May morning waiting for the opening ceremony of the 2012 Avon Walk for Breast Cancer to begin. Clouds of coffee and sunblock hung in the warm, humid air and a song about being strong against all odds thumped out from the loudspeakers like a hopped-up heartbeat.

A group of women wearing pink tulle skirts and black T-shirts embroidered ‘Tutus for Tatas’ across the chest moved toward me as I bent over to tie my sneaker. The fronts of their hats were inscribed in black sharpie: “For Mom”; “In loving memory of Susie”; “For Cathy, Barb and Allison.”

One of them greeted me when I stood up. “Hi, I’m Mary. Who are you walking for?” she asked, smiling and scanning my unadorned T-shirt for clues.

“My friend Leslie,” I said, who was diagnosed with breast cancer 10 years earlier.

The music faded as a man called our attention to the stage. “Good morning,” the speaker’s deep voice boomed. “My name is Mark and I’m walking for my three sisters who were all diagnosed with breast cancer at the same time and died within two years of each other.”

Some walkers stopped warming up their hamstrings to applaud. I reached into my fanny pack for a tissue and before anyone had a chance to recover a woman wearing a bright pink Nicki Minaj wig stepped up to the microphone. “Hello. My name is Margaret and I am 38 years old. This is my second Avon Walk. Four years ago I walked for my aunt Joanie, who is a 26-year survivor. Now, after being diagnosed with breast cancer in 2010, I am proud to say I am a survivor too.”

A woman from the Avon Foundation was the last to speak. She told us that every three minutes someone is diagnosed with breast cancer and every 13 minutes a life is lost to the disease, numbers many of us already knew by heart. I swallowed down the fear that I could become one of her statistics and applauded with the other potential victims around me as she officially opened the event.

As I started to walk, I thought about how lucky I was that Leslie and I were paired as college roommates more than 30 years ago. One evening, a month or two into our freshman year, Leslie and I walked back to our room after dinner to play backgammon, which had become a nightly ritual. We got to know each other over those games, taking turns asking questions about our families, our friends back home, and our likes and dislikes. We always sat on Leslie’s bed, made up with dark green flannel sheets and a red and black plaid wool blanket, all from L.L. Bean, a store based in Maine where her family had a vacation home. On the shelf next to her bed, she lined up three family photographs in matching black frames and a clock radio tuned to the local “Music of Your Life” station. Across the room, I had a rainbow striped quilt on my unmade bed and a poster of Tom Selleck in Magnum, P.I. taped to the wall above it.

About 15 minutes into our first game, the fire alarm went off, and as we rushed out of the room, I caught my finger in the door when I tried to slam it shut. The pain was instant and excrutiating.

Once outside, I began to panic. “I need a doctor, but I think the student health center closed at 6,” I sobbed to Leslie, holding up my swollen finger. My parents had always handled situations like this, and I wasn’t sure what to do.

“Come on,” Leslie said, taking charge. “There’s a hospital three blocks down the street that I pass every day on my way to class. We can walk.”

Five minutes later we were standing in front of the emergency room of the local Veterans Hospital. It was dark and looked closed except for the lighted sign indicating an ambulance entrance. We knocked on the locked door, and a nurse slid open a peek-a-boo panel. All we could see was her face, tilted upward as though she were standing on tippy toes.

“How can I help you?” she asked.

Leslie stepped in front of me and said, “My roommate slammed her finger in a door, and we think it’s broken. Is there a doctor we can see?”

“Is your roommate a veteran?” The nurse’s lips were thin and creased. She smiled, but only with the bottom half of her face.

“Should she be?” Leslie asked.

“If she wants to be treated here, either she or someone in her immediate family needs to be a veteran.”

Leslie looked at me. “Know any veterans, Devra?”

I shook my head, then asked, “What if I split my head open and was standing here with blood running down my face? Would I have to be a veteran to see a doctor?”

Leslie looked at her shoes and stifled a laugh while we waited for a reply. Her right leg started to shake, her tell when she was uncomfortable.

“There is a public hospital half a mile east of here. They take anybody,” the nurse said sharply. Then she lowered herself and snapped the panel shut, so hard it made my finger throb even more.

To distract me from the pain as we walked, Leslie started playing a game to see who could come up with the most gruesome injuries that the veterans-only hospital would turn away.

“What if I were carrying your severed leg while you hopped on one foot. Do you think they’d let us in?”

I knew it was my turn. “Or how about if I just swallowed a pencil and was experiencing stabbing pain in my stomach. Would she open the entire door?”

“Good one. Or what if your eyeball fell out and you showed it to the nurse through the peep hole. Would you get to see a veteran’s doctor? Get it? Peep hole? See a doctor?” Leslie’s words rode out on waves of laughter. We had to stop walking for a moment to give in to our giggles.

I was treated right away at the public hospital, and Leslie and I continued to make each other laugh throughout our friendship. In the late ’80s, we were in each other’s weddings, and when my marriage failed, Leslie offered the wisdom that helped me move on: “Dev, I’m sorry you’re hurting, but everything in life is a crapshoot, so quit your crying and live your life.”

And when she found out a long-term boyfriend dumped me around the same time she was diagnosed, she called and said, “In a lot of ways cancer is easier to deal with than a broken heart because there are treatments for cancer. You’re going to be fine. So am I.”

I participated in my first Avon Walk in 2004 to help Leslie in some way, as she helped me so many times since the night I slammed my finger in the door. Even though Leslie said she didn’t need anyone’s help, I wanted to raise money for the cure she felt we were “this close” to finding. At the opening ceremony I listened to the stories of loss and survival but didn’t relate, because even though Leslie had been fighting recurring cancer for two years, she had everyone convinced that she was going to be fine. I felt the same at the 2005 Walk, probably because Leslie was still alive.

Leslie died in 2006, a few weeks before my third Avon Walk and just shy of her 46th birthday. While leafing through an issue of Oprah magazine during my post-walk pedicure, a J. Crew ad caught my eye. The male model was our dorm manager from freshman year, a closeted, flirtatious blond artist who had a steady stream of boyfriends he didn’t think we noticed. I started to tear out the page to send to Leslie, who I knew would get a kick out of seeing it, but froze when I remembered that she was gone.

The more time passes, the more trouble I have recalling the smell of Leslie’s Clinique Happy perfume, or her quick laugh when I said something she thought was funny, or the way she made me feel safe and loved with her caring wisdom. I miss all of that. As long as she lived, she never lost her sense of humor; around her I always felt as bright and sparkly as she was to me. Gosh, I miss that, too. When she died, our story, our inside jokes, our friendship died with her, and I struggle to keep the image of us—of who I was with her and who we were together—clear in my mind. It’s as though a photograph of her is fading, which makes me feel like I am disappearing too.

I continue to participate in the Avon Walk every year, despite the unwelcome bond I now have with the other walkers who have lost someone they loved to the disease, because when I walk I replay my favorite moments with Leslie. Somehow my grief gives way to the joy I used to feel in her presence, and, for a brief time, I am whole again. Yes, I am committed to raise money to help find the cure that Leslie believed was just steps away. I fundraise and walk with the determination that breast cancer will become something that used to be, like eight-track tapes and rotary dial phones. But mostly I walk to stay connected to Leslie—my lifelong friend—and to keep the part of me that was a part of us alive.

A Walk To Remember The Saturday Evening Post

Ann Kim today: “Here I am with my two sons on New Year’s Day this year. We’re at Ocean Beach in San Francisco. They were just 3 and 7 when I was diagnosed, and now they are young men. I am so grateful for each day I have with them.” Photo courtesy Ann Kim.

Shortly before my 39th birthday, when I was taking a shower, I felt a lump about the size and shape of a pea in my right breast. I felt a chill go through my body. A week later, on my 39th birthday, I got a biopsy. When the doctor called with the results (I was setting out the birthday cake for my older son’s seventh birthday), the news was bad: I had breast cancer. I wanted to cry, but I couldn’t. It just felt surreal.

In literature and film, medicine is often depicted as a paternalistic profession, with patients given little information and expected to follow their doctors’ orders blindly. In real life, my experience was the opposite. Instead of having an all-knowing doctor telling me what to do, I found myself with a team of doctors relying on me to make the critical treatment decisions. I was like a president with advisors, but I knew nothing about the topics, and the choices and the information were overwhelming. What I expected was Dr. Brilliant Guide; what I got was Dr. Me.

My first appointment was with a pre-eminent breast surgeon at a top-rated comprehensive cancer center. She carefully laid out the options for me: lumpectomy with radiation or mastectomy with reconstruction. The lumpectomy would mean a less invasive procedure and a quicker recovery but also require several weeks of daily radiation and a lifetime of mammograms and MRIs. The mastectomy would entail more invasive surgery and a longer recovery time but eliminate the need for radiation and ongoing screening. Long-term survival odds were the same. My surgeon had no recommendation either way.

Anxious to get her to cast a vote, I tried a personal approach. I had Googled my surgeon before the appointment and found that we were of the same age and ethnicity, and we were both mothers. “You and I could be sisters—twins, even,” I told her. “If you were in my shoes, what would you do?”

Ann Kim during chemotherapy in 2005: “This is one of the few photos I have of myself when I was bald. My sons and I are cuddling together in bed during a trip to Yosemite in the winter.” Photo courtesy Ann Kim.

She paused before answering. “Whenever women ask me that, I tell them that it’s a personal decision, and that I can’t make it for them,” she said. “But when I look at you, I see myself. I would choose a mastectomy with reconstruction.”

I was grateful for her answer but also frustrated on behalf of other patients. Why do doctors express their much-more-informed opinion so reluctantly?

I had more decisions to make when I met with a plastic surgeon. He laid out the options: saline implant, TRAM flap (which uses skin, fat, and muscle from the belly region to construct a breast), or LAT flap (which uses skin, fat, and muscle from the back region to construct a breast). I chose to get an implant, but I developed severe capsular contracture, which is when scar tissue forms around the implant and causes painful stiffness and hardening of the tissue. After multiple surgeries, I had to remove the implant altogether. In retrospect, I wish I’d considered the choice of no reconstruction at all, but it was not something that I even thought to discuss with the plastic surgeon, nor did he mention it to me.

The hardest phase of my medical training was choosing an oncologist, the person responsible for administering chemotherapy and other systemic cancer treatments. Weeks had passed since my surgery, and I was convinced that the cancer was already beginning to spread. I wanted to begin chemotherapy right away. But the oncologist offered me the most intimidating set of choices yet.

I could take four rounds of Adriamycin plus Cytoxan, either at four-week or three-week intervals. I could add four rounds of Taxol or Taxotere, again at either four- or three-week intervals. I could participate in a clinical trial in which I would receive either a new drug called Herceptin or a placebo. After my chemotherapy ended, I could choose to take five years of an oral hormonal drug called Tamoxifen, or I could suppress my ovaries by taking a drug called Lupron or Zoladex and take five years of an Aromatase Inhibitor such as Letrozole (brand name Femara), Exemestane (Aromasin), or Anastrozole (Arimidex), or I could take five years of Tamoxifen and follow it up with another five years of an Aromatase Inhibitor.

My head was spinning. Having spent an hour describing the options, the oncologist had run out of time and had to move on to her next patient. Rather than recommending a particular course of treatment, the oncologist told me and my husband to go home and think about it and make an appointment to meet with her again.

I didn’t want to wait several more weeks mulling over treatments I didn’t really understand. At my friend’s suggestion, I met with another oncologist. He offered the same options as the first oncologist but recommended a specific course of treatment and gave strong supporting reasons for it. I appreciated that he was advocating an aggressive approach (adding a third chemotherapy agent and combining ovarian suppression with an Aromatase Inhibitor). But, mostly, I was grateful for a straightforward answer. He became my oncologist.

For young women with breast cancer, treatment decisions often extend beyond surgery, radiation therapy, and oncology to medical specialties such as genetic counseling, fertility planning, gynecology, psychiatry, physical therapy, and primary medicine. Unfortunately, even at a comprehensive cancer center, the patient must coordinate these various disciplines. And if you go “a la carte” like I did, mixing and matching doctors in different practice groups and at different hospitals, good luck.

In the end, I had to create an Excel spreadsheet just to keep track of my appointments: breast surgeon every six months; mammogram every year (ideally just before the breast surgeon visit so that we could discuss the results); MRI every year for the first two years (ditto, but scheduled six months from the mammogram); oncologist every four months for the first five years, then every six months thereafter; ditto for the blood test with tumor markers; PET/CT every year for the first three years; bone density test every year for the first five years (to track the bone thinning effects of the Aromatase Inhibitors); MUGA heart scan every few months for the year of Herceptin (owing to the cardio-toxic effects of Herceptin and Adriamycin); gynecologist every six months; primary physician every year; and so on. I was able to keep track of this because I’m fairly organized. But what about most people?

In many respects, the collaborative approach that doctors take to cancer treatment is welcome. No one wants a high-handed doctor making treatment decisions without the patient’s involvement or understanding. But a patient can’t in the end play the role of doctor. We might want to know why a doctor is recommending something; but we still want a recommendation. Also, many of us need a guide just to navigate all the appointments and logistics, which can be Byzantine.

Today, nearly eight years after my initial diagnosis, I continue to be vigilant in monitoring my health. (Hormone-sensitive cancers like mine have a “long tail”—meaning they can recur 10, 15, even 20 years after diagnosis.) I read articles and books about cancer. I attend lectures and take notes about the latest treatments. And I participate in a breast cancer support group.

If, knowing what I know now, I were able to go back in time and advise myself on how to be Dr. Me, I would have said three things that I also say to new acquaintances in similar circumstances. The first is that you should always bring a family member or friend to your appointments and have him or her take notes. Often, we patients are so overwhelmed that we can’t remember what we were just told or don’t ask any questions. The second is that you must take care of your whole self. Treat yourself to delicious and healthful food every day. Watch a funny movie and laugh with your friends. Take naps and hot baths as needed. The third is that you should feel free to complain. I have seen too many friends suffer in silence, whether it’s nausea from chemo (doctors often prescribe the cheapest anti-nausea drugs before moving up to the more powerful stuff) or simply trouble getting an appointment. If the front desk or support staff are unhelpful, tell your doctor—doctors don’t want to lose you as a patient.

In an ideal world, of course, no patient would have to shoulder so many responsibilities along with trying to get well. One of the best improvements that could be made would be for patients with cancer to have a “patient advocate.” If you were diagnosed with cancer, the medical center would partner you with a professional patient advocate who would guide you through the cancer treatment process. The patient advocate would set up appointments for you, make sure your care was coordinated, and offer general health-related suggestions (alternative treatments, massage, nutrition classes, support groups). The advocate might even accompany you to appointments and help you with decision making. This would go a long way toward letting those with serious conditions have the luxury of being patients, so that they don’t have to be Dr. Me.

Ann Kim is the president of Bay Area Young Survivors (BAYS), a support group for young women with breast cancer in the San Francisco Bay area.

Article originally published at Zócalo Public Square (zocalopublicsquare.org).

Going it Alone The Saturday Evening Post

Marc Silver discovered this firsthand when his wife was diagnosed with breast cancer in 2001, and though he stood by her and eventually figured out how to be a good caregiver, he’s the first to admit he made plenty of mistakes along the way. After their ordeal (his wife is doing fine at present), he wrote an instruction manual to help other caregiving-challenged men. His book is called Breast Cancer Husband, How to Help Your Wife (And Yourself) Through Diagnosis, Treatment, and Beyond. I recently caught up with Marc to talk about his experiences and to find out what advice he has for other men.

Q:  Why do men need extra help when it comes to caregiving?

A: Caregiving is a role that a lot of guys are unfamiliar with, and particularly in the case of breast cancer, it is thrust upon them with no time for preparation. Personally I just remember feeling totally clueless and getting a few things completely wrong.

Q: For example?

A: Well, my wife Marsha called me immediately after her diagnosis. She’d just been told out of the blue that she had breast cancer. She was looking for some husbandly advice and solace, and my first reaction over the phone was, “Ew, that doesn’t sound good.”

Q: Uh, oh.

A: It gets worse [laughs.] We continued to talk a bit more, but only about logistics, when what she was needing at that point was sympathy and compassion. Then, at the end of the conversation I hung up, stayed at work all day, and didn’t come home until the usual hour.

Q: What did your wife say about that?

A: Marsha told me later, “I must have called the wrong husband.”

Q: In doing research for your book, did you find that your initial reaction—let’s be nice and describe it as missing her emotional cues—was a common one?

A: There are plenty of examples of men who ran straight home to be there for their wives when a cancer diagnosis was made. But yes, many men make mistakes like these, and I’ve heard of worse.

Q: Like what?

A: After a speaking engagement for my book, a couple came up to me and the husband told me that his reaction to his wife’s diagnosis was, “Well, you want to stop for dinner at Hooters?” I asked him if he was trying to be ironic or funny, but he insisted he was just thinking about a good place to get a meal.

Q: Sounds like men can’t cope initially and go into autopilot. Is this denial?

A: Yes, I think so. But it’s a very human reaction. One therapist I interviewed for the book said, “Nobody is sitting there saying, ‘Oh gosh, I hope I get to be a caregiver for a loved one who is diagnosed with cancer.’”

Q: So, guys shouldn’t beat themselves up too much about initial blundering?

A: No, they shouldn’t. That is very important. It is inevitable that you are going to do things that are going to tick your wife off or be not the kind of things she needs at that time. But you can learn from that. A lot of woman said to me that the motto for the husband is: “Shut up and listen.”

Q: Is there something inherently different about men that makes it harder for them to be good caregivers? Or, are men just not socialized to get it? Is it nature or nurture?

A: In my research I found a little bit of both. Men are simply not taught to tune in to others emotionally the way women are. On the nature side, doctors point to studies showing women have more of the hormone oxytocin, which promotes empathy.

Q: Still, it sounds like you’re saying, with some help, men can and do learn to be better caregivers.

A: Yes, absolutely. A big challenge is that men like to be problem-solvers. Instead, they need to learn that their role, as a caregiver, is to be an echo or a foil: Let her talk things through with you without interrupting to say, “here’s what you should do.” You’re not supposed to be in charge here. She is the boss.

Q: Does that make you the assistant?

A: Yes, exactly.

Q: Can you give an example of being supportive, without taking charge?

A: It is very common for a patient to be overwhelmed by all of the medical information. So, it’s important to join her at all medical appointments. Make lists of her questions for the doctors prior to each visit, and keep the list in front of you during the visit to make sure all of them get answered. Also, take good notes on these medical conversations so you can go over the details later.

Q: Your book title stresses helping your wife and yourself. How so? Isn’t that selfish?

A: Part of what you have to do as the caregiver is to be selfish sometimes. Whether it’s going out for a bike ride or watching a movie you like. You need time for yourself to recharge.

Q: So, if caregivers have a need to, say, go play golf or take a bike ride for a few hours, that’s ok?

A: Yes, but I would always ask my wife’s permission first. I interviewed Cokie Roberts for the book. She said when she was going through breast cancer, friends would call up and ask what could they do. And her first response was: “Play tennis with my husband.” It is certainly much harder to be the patient, but it is tough to be a caregiver too.

Steven Slon is the editorial director for The Saturday Evening Post. This column was first published by Beclose.com.

Helping Men Become Better Caregivers The Saturday Evening Post

Dorothy,

Pocatello, Idaho

Don’t give up soy and flax yet! While it’s true that estrogen can increase cancer risk—especially when abnormal cells have “docking stations” (called receptors) for the powerful hormone—the estrogen-like compounds in soy and flax may actually provide health benefits. Post advisor Dr. Walter Willett, chairman of the Department of Nutrition at the Harvard School of Public Health, explains:

“Soybeans and flaxseed contain phytoestrogens, which react with the same receptors as estrogen from ovarian or fat tissue. Phytoestrogens, which are sometimes called ‘plant hormones,’ may have estrogen-like effects. However, they trigger a far weaker response than do the estrogens produced by the body. In fact, consuming soy and flax may prevent stronger-acting estrogens from binding to the receptor sites and produce an overall antiestrogenic effect, similar to the way tamoxifen, a breast cancer drug, works.

“The potential benefit has caused many to question whether the high soy consumption in Asian populations contributes to the low breast cancer rates in those countries. Although studies have not been conclusive, some of the data suggest increasing soy intake during adolescence or early adulthood may decrease cancer risk. Alternatively, studies do not show a direct correlation between high soy consumption and the risk of breast cancer.

“While I wouldn’t recommend loading up on large amounts of flax, tofu, soy milk, and other soy products, I don’t think it’s necessary to completely avoid them. Stay away from phytoestrogen supplements, though. They may increase your consumption too much. Instead, focus on staying lean and physically active to reduce body fat, which is a major source of estrogens. And of course, schedule regular checkups with your physician to discuss treatment options and answer any questions that may arise.”

Of the foods that Americans eat, soy and flax have the highest content of phytoestrogens. Other sources (with lesser amounts) include: sesame seeds, wheat, berries, oats, barley, dried beans, lentils, yams, rice, alfalfa, mung beans, apples, carrots, pomegranates, and wheat germ.

Soy, Flax, and Breast Cancer The Saturday Evening Post

When to consider

Q: A new diagnosis of breast cancer is overwhelming. At what point should women explore their reconstructive options?

A: The primary concern at the time of diagnosis is: Get rid of this cancer. Decisions are being made under fire, and issues such as breast reconstruction tend to be put aside. But a new approach, a multidisciplinary one, is being utilized at medical centers that specialize in breast reconstruction. When cancer is first diagnosed, a breast surgeon, a plastic surgeon, a medical oncologist, and a radiation oncologist provide input as to what needs to be done—and when.
Discussing options for reconstruction at the time of diagnosis may also help a woman begin to feel more comfortable about what is happening to her—she can see light at the end of the tunnel. Alternatively, she might say, “You know what, that’s not for me.” And that’s fine. She is empowered to make an educated decision about her options.

What are the options?

Q: Breast reconstruction options fall broadly into two categories: breast implants and using the patient’s own tissue. What factors determine the best approach?

A: The primary factor is the patient’s anatomy. Does she have sufficient tissue in the abdomen, back, or other areas to transplant to the chest? If so, using the patient’s own tissue is an option. When that is not the case, implant-based options are the only choice. Another factor, disease severity, may affect the timing of breast reconstruction. For example, plastic surgeons may delay using the patient’s tissue for reconstruction until radiation or chemotherapy is completed—which brings us back to why a multidisciplinary approach is so important.

How it’s done

Q: Breast reconstruction surgeons sometimes utilize a balloon-like device called a tissue expander. What is it and how does it work?

A: A tissue expander is a temporary device that is made of a material similar to plastic. We support the device with an internal sling called AlloDerm that is attached to the chest wall. After the surgery, the expander is filled with saline through a built-in port, and it slowly stretches the patient’s skin until there is enough space to perform the second stage: opening the incision, taking out the expander, and placing a final breast implant. Putting in a tissue expander mandates two stages.

What is AlloDerm?

Q: What is the sling made of, and does it remain in place?

A: We use AlloDerm, a regenerative tissue matrix derived from donated human tissue and developed by LifeCell Corporation. It acts as a replacement for tissue that is removed during the mastectomy. Through a propriety process, all of the cells are removed from the donated skin without damaging the skin matrix, preserving the biochemical components necessary for new tissue to grow into it. Basically, AlloDerm is accepted by the patient’s body and ultimately becomes a part of it.

Q: How long has AlloDerm been available?

A: AlloDerm was introduced in 1994 as a skin graft and has been utilized in thousands of burn patients without any issues. It was pioneered for post-mastectomy breast reconstruction in about 2001, and has since become the state of the art approach for breast implant reconstructions.

Q: Why is AlloDerm so helpful for breast reconstruction?

A: AlloDerm acts as a hammock for the breast implant, allowing it to lay naturally. AlloDerm also addresses some of the technical pitfalls of breast implant-based reconstruction—problems such as controlling the position of the implant, defining the fold, and camouflaging the implant. In addition, recent advances with AlloDerm allow us, in many cases, to avoid using a tissue expander and proceed directly to placing an implant. Immediately after the mastectomy, the patient wakes up with her final implant, and the AlloDerm to support it and create the breast shape. Quite frankly, we are able to achieve more reliable results than before the advent of this technique. AlloDerm provides predicable results and improved outcomes for more women than was previously possible.

Safety issues

Q: There have been concerns in the past about silicone gel implants. Are they safe?

A: New-generation gel implants have been very well studied and safety is no longer an issue. Before 1992, the gel being used in implants was so thin that if a crack developed, it would spill out and could cause local problems such as the formation of scar tissue. As a result, a moratorium was placed on the implants and, for the ensuing 14 years, a woman could get a gel implant only through a study protocol. Data was collected on thousands of women who received a new generation of implants with very viscous contents. In 2006, the FDA approved the newer implants, which have a high safety profile.

Q: What are the common reconstruction procedures that make use of the patient’s own tissue?

A: Across the country, the most common reconstruction procedure that utilizes tissue from the patient’s body is called the TRAM (Transverse Rectus Abdominus Myocutaneous  flap). During this surgery, surgeons take skin and fat tissue from the abdominal area and transfer it to the chest wall. In addition, we remove and transfer the abdominal muscle that carries blood vessels needed for the skin and fat to survive. The TRAM flap procedure flattens the abdominal donor site, similar to the way that a tummy tuck works. However, removing the muscle can sometimes cause problems. In addition, it can take longer to recover from donor sites on the abdomen as compared to other areas.

Perforator flap procedures also involve transferring the patient’s skin and fat tissue from the abdomen to create a breast shape. The important difference is that no muscle tissue is removed. Instead, we tease out only the blood vessels that supply the skin and fat. Then, under a microscope, we connect the vessels from the flap to those on the chest wall in order for that tissue to survive. The most common perforator flap, the DIEP (Deep Inferior Epigastric Perforator), also allows a flat donor site. It is a complex procedure which, again, may involve a longer recovery because tissue is taken from the abdomen.

Who pays?

Q: Do most insurance companies cover the cost of breast reconstruction?

A: The Federal Women’s Health and Cancer Rights Act of 1998 protects women with breast cancer who need a mastectomy. Based on federal guidelines, the Act mandates that insurance also cover all stages of breast reconstruction after mastectomy. Women often undergo multiple stages to complete a final reconstruction. As new procedures are developed, it may take time to obtain coverage. At this point, however, all procedures that I perform in my practice—tissue expander, implant-based, and reconstructions using patient tissue, are covered.

Obstacles

Q: A recent survey from the American Society of Plastic Surgeons shows that seven of 10 women eligible for breast reconstruction don’t know their options. Why is this?

A: Old habits die hard. About 100 years ago, William Stewart Halstead, a famous general surgeon, reported the first successful mastectomy procedure for breast cancer. And he warned against reconstruction procedures because he believed that it hindered the potential for cure and might compromise the patient’s health. That belief prevailed until the early 1970s when early reconstructive procedures with implants were done. In the 1980s, general surgeons began to perform modified radical mastectomy and skin-sparing mastectomy, and new reconstruction techniques—tissue expansion and flap procedures—were developed. And breast reconstruction continues to gain popularity. Today, genetic testing for breast cancer is available. People who do not have cancer are deciding to prevent future problems by having mastectomies and reconstructions.

Yes, 30 percent is a low number, but it is definitely on the upswing. We, as plastic surgeons and the American Society of Plastic Surgeons, are aware of the reality that women living in large metropolitan areas are more likely to be offered breast reconstruction than those in small communities. But awareness is increasing and Internet information is empowering women to learn about their options. The word is getting out and the options are much more diverse than 10 years ago.

Resources

More information about breast reconstruction is available from the American Society of Plastic Surgeons, including how to find surgeons who are board certified and trained in these procedures. Click here for a comprehensive resource for breast reconstruction co-developed by Dr. Israeli and here for one sponsored by LifeCell.

Breast Reconstruction: A Woman’s Choice The Saturday Evening Post

P
New York

How Cancer Spreads The Saturday Evening Post

“We’ve got a few targeted therapies that can dramatically improve your prognosis if you’ve been diagnosed with breast cancer, but we know that they’re not for everyone,” says pathologist Dr. Olga Falkowski. “These new tests will help doctors quickly and accurately identify women whose cancer is HER-2-positive, thus getting them the best possible treatment in the shortest possible time.”

A second test, silver enhanced in situ hybridization (SISH), deposits tiny amounts of silver to help detect HER-2 genes in cells. Used in other countries, it is awaiting FDA approval in the United States.

Breast Cancer: Better Test, Better Treatment The Saturday Evening Post

For details about each research advancement, visit cancer.net

The Top Cancer Research Advancements of 2008 The Saturday Evening Post

Two fitness products help strengthen muscles safely and with lasting results while at home or away. Rotating handles on the Perfect Pushup allow beginner, intermediate, and advanced exercisers to work the chest, arm, shoulder, and back muscles while reducing strain on wrist, elbow and shoulder joints. The Rotater device helps stretch Healthy shoulders and rehab sore ones by maintaining proper joint positioning to help athletes, seniors, and breast cancer survivors increase shoulder flexibility and range of motion. Both items are available online.

Pump It Up The Saturday Evening Post