Screening, Surveillance, and Survivorship after Breast Reconstruction

Abstract

In this chapter the recommendations for breast cancer screening, surveillance, and survivorship after breast reconstructive surgery will be discussed. The average risk patient, high risk patient, and the breast cancer survivor after breast reconstruction of any form will be outlined with pertinent challenges, complications, and patient related concerns detailed. The lifestyle changes and psychosocial concerns of patients after breast reconstructive surgery will also be described. The patient’s journey is the central theme of this chapter, as are the surgical choices they make and how that might affect their future care.

1. Introduction

When a patient with a breast related concern is faced with challenging discussions regarding breast reconstruction options, there are many variables that must factor into the decision making process. Risk assessment should be performed so that the patient can understand if they are at average risk for breast cancer or at an elevated risk based on quantitative risk assessment models. The indications for surgery should also be fully understood as that can affect the options available to the patient. Any treatments that may be required after surgery should also factor into the decision making process. Once breast reconstruction has been performed it has the potential to alter screening, surveillance, and survivorship recommendations and the patient, the surgical oncologist, and the plastic surgeon must be prepared for those challenges.

In order to facilitate the decision making process all the ramifications of breast reconstruction must be disclosed to the patient and the patient care team. In this chapter the recommendations for breast cancer screening, surveillance, and survivorship will be discussed. The average risk patient, high risk patient, and the breast cancer survivor after breast reconstruction of any form will be outlined with pertinent challenges, complications, and patient related concerns detailed. The lifestyle changes and psychosocial concerns of patients after breast reconstructive surgery will also be described. The patient’s journey is the central theme of this chapter, as are the surgical choices they make and how that will affect their future care.

2. The average risk patient

One in eight women will develop breast cancer. This correlates with an approximately 12% average risk that a woman will develop breast cancer in their lifetime. A woman may decide to proceed with breast reconstruction in varying forms and for many different reasons. In the non-cancer setting breast reconstruction can take the form of breast augmentation, fat grafting, tissue transfers, or silicone injections. These interventions may seem indolent to the patient, but to the surgical oncologist and the breast radiologist even these benign procedures can lead to challenges in future breast cancer screening.

If a patient chooses to undergo a breast procedure of any kind they must be informed that this will lead to changes in the architecture of the breast. Injection of any material into the breast can lead to internal changes and scarring that can be hard to differentiate from a malignant lesion. This finding may then need to be biopsied to determine its true pathological derivation. The anxiety that surrounds a callback for abnormal imaging and the need for a breast biopsy is substantial and should be taken into account. Injection of a foreign material into the breast can lead to pronounced inflammatory changes, including a cellulitis of the breast necessitating treatment with antibiotics and steroids. The treatment of these findings and subsequent breast changes also have consequences to be considered.

A patient who undergoes breast augmentation will still need to undergo screening mammography in order to provide early cancer detection. For the patient with breast implants who needs to undergo routine screening mammography there are some special concerns that should be noted. Patients who have implants are often concerned that the mammogram itself will rupture them, and this is not true. What does need to be considered is that it becomes increasingly more challenging to compress the breast appropriately for the patient with breast implants and all the breast tissue may not be seen clearly. The tissue near the implant will be hard to compress and thus achieve the magnification necessary to see the calcifications or architectural distortion that may indicate an abnormality. Approximately 20% of a patient’s breast tissue may not be visualized well after breast augmentation when undergoing screening for breast cancer.

Patients who have a family history of breast cancer who do not meet the criteria of a high risk patient may choose to have a prophylactic mastectomy with reconstruction. That reconstruction could be either implant based or with autologous tissue transfers. Which form of reconstruction is appropriate must be decided on a case by case basis in regards to that patient’s particular history and concerns with the surgical oncologist ensuring that the patient understands all the risks associated with these prophylactic procedures. The recommendations for further care in this setting will be discussed in the section related to high risk patients as they would be similar.

The recommendations for screening of the patient at average risk for breast cancer include yearly mammography after the age of 40. This is recommended to continue until the age of 75 or at which time 10 yrs. or less of life expectancy is estimated [1]. The aforementioned breast changes with difficulty in the establishment of a benign or malignant lesion and subsequent need for a tissue diagnosis can lead to mental and physical discomfort in the fear and anxiety that this can provoke, as well as in the procedure itself. Patients should be counseled accordingly prior to breast reconstruction as to the risks involved, and that this may lead to additional breast findings and breast biopsies in the future.

3. The high risk patient

A patient who’s risk for breast cancer has been assessed and whose risk is greater than or equal to 20% is classified as a patient at high risk for breast cancer. These assessments are made based on models such as the Gail Model or Tyrer-Cusick Model of risk assessment. In these models the patient’s hormonal history, breast history, and family history of breast and/or ovarian cancer are utilized to estimate that individual’s lifetime risk for breast cancer. It can thus be understood that with an elevated risk for breast cancer and with family members who have undergone treatment for breast cancer that the patient may want to do everything they can to prevent this from occurring. High risk screening paradigms as well as prophylactic procedures are then discussed with these patients, as well as genetic testing for predispositions to cancer where appropriate [2].

If an individual who is at elevated risk for breast cancer does not wish to undergo prophylactic/preventive surgery, most often in the form of a bilateral mastectomy, they will be followed closely according to the guidelines documented for that patient population. High risk screening includes two clinical exams yearly as well as annual mammography and annual MRI [2]. Many providers and surgical oncologists will recommend that the patient stagger the recommended breast imaging at six month intervals so that they do not proceed with a year between these imaging modalities and can be seen twice a year with new imaging available at that visit.

When the decision has been made to proceed with prophylactic bilateral mastectomy the patient must first understand that this does not mean that they could never get breast cancer. Surgical intervention has been documented to decrease the risk of breast cancer development by 90%, but that risk is not zero. The patient is then given the option of undergoing immediate breast reconstruction or delayed breast reconstruction. If the patient desires breast reconstruction they then must choose which type of reconstruction they would like to have. Typically the choice is between an implant based reconstruction or autologous tissue transfer.

With an implant based reconstruction the common challenges noted post-operatively include implant rupture (approximately 4% risk in the first 2 years post-operatively and nearly 50% at 10 yrs), capsular contracture, rippling of the skin, and migration/flipping of the implant. In many settings a temporary tissue expander implant is used to stretch the skin post operatively so that an appropriate breast size can be reached, necessitating additional surgery for the final stage of reconstruction. Breast implants are not meant to last the entire life-span of the patient and often need to be replaced after 10 yrs. in vivo. Another more recent concern has been documented in cases of implant associated B-Cell lymphoma, mainly in regard to textured implants placed 8–10 yrs. ago [3].

For the patients who undergo autologous tissue transfers as part of their breast reconstruction, the following should be discussed. It should be noted that the site where the donor tissue is to be removed from is separate and at risk for its own set of complications. The overall failure rate of these reconstructive techniques can be quoted at 1–3% with a wound infection rate estimated at 5–12% [4]. The gravity of these surgeries should be relayed, and the prolonged recovery time explored. These surgeries are often discussed as a one-step surgery, in that there is no required second step to complete the reconstruction, but many patients undergo additional minor procedures to obtain the cosmetic result desired.

After autologous tissue transfer breast reconstruction, it should also be stated that the scarring and internal remodeling of that tissue can take a quite prolonged course and that the patient might note changes to the consistency of that tissue months after surgery. This is most commonly seen in areas of fat necrosis that develop in the autologous tissue, presenting like abnormal chest wall masses that can be quite concerning for a breast malignancy, requiring further diagnostic evaluation and potentially biopsies of that area. In the patient who is at elevated risk for breast cancer the additional changes after autologous tissue transfer reconstruction that may be noted and need further evaluation should be explored in pre-operative discussions to prevent undo anxiety and ensure that they get proper care should a new finding be discovered.

4. The breast cancer survivor

In the case of the breast cancer survivor the first step in delivery of their care may be recognizing that these patients are facing a traumatic experience and that their ability to make decision may be hampered by anxiety, denial, shock, along with difficulty understanding the complexity of breast cancer care. Additional time to make these life altering decisions can be useful in this instance to allow for time to process the diagnosis and treatment options, to talk to other family members and loved ones who can assist them through this process, and to seek second opinions if desired to ensure the patient understands what they are facing. Additional office visits may be necessary to review the options or talk to additional care givers if the patient is noted to be struggling with the decision on how best to proceed. A patient must be able to develop a sense of trust in their surgical team prior to proceeding and the time necessary to establish this is quite variable.

When the surgical plan for the breast cancer patient is devised, and all the options have been explored, if the patient proceeds with unilateral or bilateral mastectomy with reconstruction there are pre-operative, peri-operative, and post-operative considerations to be disclosed. Pre-operative concerns to be addressed include the timing of surgery, pre-operative risk stratification, as well as a clear delineation of all the risks and benefits to this approach. It should be noted here that according to current guidelines the surgical oncologist is recommended not to encourage prophylactic contralateral mastectomy for the breast cancer patient in the setting of no genetic predisposition to cancer as this greatly increases the surgical risks involved with very little risk reduction, as the risk of contralateral breast cancer is quoted at 0.4% per year [5].

4.1 The pre-operative breast Cancer patient

Current standard of care dictates that we should pursue surgical intervention within 30 days of the diagnosis of cancer. With the addition of the consultation with the plastic surgeon and the coordination of multiple surgical calendars, this can be quite challenging to obtain. Working together to obtain the earliest surgical date possible becomes incredibly important. Risk stratification in regards to cardiac clearance, pulmonary optimization, and renal status should also be factored into the process for those patients who require it. Any additional imaging, staging studies, genetic testing, and any other pre-operative referrals should be expedited as much as possible. The need for pre-operative systemic therapy must also be taken into consideration when treating a breast cancer patient. In the modern era pre-operative chemotherapy and immunotherapy are commonly used to treat triple negative breast cancer and Her-2 neu targeted therapies are used to treat Her-2 neu (+) breast cancer when appropriate. Neo-adjuvant chemotherapy prior to surgery in this setting is associated with a 60% compete pathological response rate, and the pathological response rate noted is then used to dictate further systemic treatment. The breast care team, with the keystone being the breast cancer care navigator, are integral to ensuring that the pre-operative process is facilitated as much as possible. Working with the patient through each step of the journey so that they are aware of how the process is unfolding is critical during this very stressful point in their life. Clear expectations of what to expect will help the patient immensely as they navigate their care.

4.2 The peri-operative breast cancer patient

Peri-operatively the expected hospital course, pain management, wound care, drain care, recovery experience, and post-operative limitations should be clearly delineated. If able the psychological aspects of losing a breast, or both breasts, should be approached with the patient as well. Many institutions have a policy in place where a patient is discharged to home on the day of their procedure if they are undergoing implant based reconstruction. In this setting it can be incredibly helpful to have a staff member call the patient the day after the procedure to ensure no complications have been noted post-operatively. Clear instructions on what to expect as well as what to look out for are usually provided by the physician or surgical facility of choice to assist with this. If the patient undergoes a period of 23 hour post-operative observation many of these concerns can be evaluated and readdressed prior to their discharge the following morning. After autologous tissue reconstruction patients are often admitted to the hospital with lengths of stay approximating three to five days.

Pain management is another critical component of the peri-operative discussion. Many great strides in multi-modal pain management have been documented and should be applied where appropriate. Multi-modal pain management can include Tylenol, NSAIDS, and muscle relaxants; in addition to local nerve blocks to lesson or alleviate the need for post-operative narcotics. Many patients voice anxiety concerning the level of pain that they are going to experience after surgery and they can be comforted that a pain management approach that attempts to control pain from many different angles will be used.

Drain care, post-operative wound care, and any specific limitations should also be addressed in the peri-operative phase. What the recovery period after unilateral or bilateral mastectomy may look like is another essential component of these discussions. A recovery period of approximately 30 days is not unreasonable. Drains that remain in place for 2–3 weeks is not uncommon. Bathing restrictions while the drains are present is often noted as well as lifting restrictions for up to four to six weeks post-operatively. There are often physicians who prescribe antibiotics post-operatively for the time frame in which the drains remain in place as well. Working with the nursing staff who provides this information to the patient to ensure that it is correct and that the patient is able to assimilate this information is essential to decreasing the incidence of post-operative complications noted, such as; hematoma/seroma formation, infection, and other wound related complications, while ensuring their compliance with the instructions.

After discussions in the pre and peri-operative phase of the breast cancer patient’s surgical care it may be noted that they might benefit from additional assistance. A psychologist or social worker may need to be involved if the patient requires additional resources to cope with the psychosocial aspects of their health. A physical therapist may be required to assist with return to full range of motion as the patient recovers. For the elderly or infirm a subacute nursing facility may be necessary to assist with their daily activities until they improve and are able to return to their baseline health status. A holistic approach to the individual patient and their care is necessary to achieve the best outcome and can require a multidisciplinary approach.

4.3 The post-operative breast cancer patient

The breast cancer patient’s journey into survivorship often is felt to begin in the post-operative period. For the patient who chooses to undergo mastectomy with reconstruction that journey begins with accepting an entirely new body image; and for a woman, the loss of an organ very deeply tied into their gender identity, sexuality, and maternal nature. From a technical perspective long term complications after mastectomy and reconstruction include numbness to the skin of the mastectomy flaps, loss of the nipple areolar complex in many cases, post-operative pain, and lymphedema. If adjuvant radiation is required after mastectomy with reconstruction this can increase the risk of lymphedema noted as well as the previously described risks of capsular contracture and skin rippling after implant reconstruction. In general the skin sparred at time of mastectomy can become darker, thicker, and have decreased wound healing capabilities. All these aspects can be combined into a cosmetic result that is less pleasing then imagined prior. The risk of a patient’s breast cancer diagnosis necessitating adjuvant radiation should thus be broached to allow for complete disclosure, often leading to a recommendation for delayed reconstruction should that risk be high.

In the post-operative period there also remains a risk that the patient will develop a wound infection or wound dehiscence, leading to implant removal for those patients who chose to undergo an implant based reconstruction. For the patient who undergoes a nipple sparing mastectomy there is a noted risk of loss of the nipple areolar complex. The mastectomy flaps themselves are at risk of ischemia and thus tissue loss that may require debridement, skin grafting, or other procedures not excluding removal of the implant to allow for wound closure and another attempt at delayed reconstruction. In the patient who undergoes autologous tissue transfer reconstruction, as noted prior, the wound related challenges discussed also apply to the site of tissue harvest. If abdominal muscle is taken at time of autologous tissue transfer this infers an associated risk of abdominal wall hernia formation that should be taken into consideration.

In the peri-operative to immediately post-operative period after autologous tissue reconstruction there is a risk that the whole tissue graft will be lost should a post-operative complication occur, such as venous outflow obstruction or arterial occlusion. In certain settings leeches can be and have been applied to the reconstructed breast flap in an attempt to alleviate venous congestion and preserve graft function. This would be quite a troubling and unexpected event to the patient who is unaware that this is a potential outcome. In the setting of autologous tissue transfer reconstruction it can be also noted that areas of fat necrosis can develop that can be quite large and concerning. Tissue contracture may occur to a degree that necessitates fat grafting or other surgical approaches to filling the defect that remains. Multiple procedures may be necessary to achieve the final outcome desired and close clinical follow up is often required during this period to ensure optimal outcomes and that a recurrent cancer does not develop.

5. Life after breast reconstruction

The long-term effects of breast reconstruction after mastectomy in the prophylactic setting or in the breast cancer patient must also be mentioned at this time, as they are quite significant. The long-term outcomes these patients must contend with include physical and psychosocial concerns. The physical ramifications of breast reconstruction include but are not limited to; post mastectomy pain, long-term surveillance of the reconstructed breast, continued maintenance of the reconstructed breast, and decisions around nipple reconstruction/tattooing. The psychosocial aspects include loss of self, loss of sexual identity, loss of libido, and inability to connect with their partner physically and emotionally.

In regard to the physical components of life after breast reconstruction, post mastectomy pain may be the most common complaint noted among patients. Physical therapy, injections with local anesthetics, muscle relaxants, and medications for nerve pain can be used to assist in control of these symptoms. If the nipple areolar complex was removed at time of surgery, a decision must be made as to whether or not the patient would like to proceed with reconstruction of the nipple areolar complex. This may be performed via multiple different techniques, including 3-D tattooing. The long-term maintenance of the reconstructed breast previously mentioned can include things such as fat grafting and tissue transfers should areas of deficit be noted. Should the patient undergo an implant base reconstruction and reach the shelf life of that implant, the implants may need to be replaced. Long term maintenance of the reconstructed breast can also include further evaluation if new concerns develop, imaging of new findings with appropriate tissue diagnosis if necessary, and biopsy of areas of fat necrosis contained within the breast reconstructed with autologous tissue. Revision of the reconstruction may be required based on the cosmetic changes that appear overtime.

Long-term surveillance of the reconstructed breast and evaluation for cancer recurrence entails clinical exams at the discretion of the medical oncologist and surgical oncologist. This frequently means clinical exams every three to four months for the first two years and biannual exams between the second and fifth year after diagnosis. Yearly breast exams at the very least to follow. There would be no need for screening mammography to be performed after bilateral mastectomy with reconstruction, though imaging may be used in the diagnostic setting to work up a new breast related complaint.

The psychosocial ramifications for the patient after mastectomy with breast reconstruction are much harder to elicit and to quantify. Many if not most patients do not feel comfortable discussing with their doctors the most intimate aspects of their personal lives. It is noted however that many woman who have undergone these procedures have trouble with a negative body image, feeling that they are hideous to themselves and others post-operatively. They can sometimes feel less than human in losing a part of themselves. They can certainly feel like they have lost an essential part of what makes them a woman, harming their sense of gender and sexual identity. Physical intimacy with a significant other or spouse is a challenge for these individuals and many of them do not engage with their loved ones on that level for a prolonged period of time. A woman’s breasts are also deeply rooted in their maternal nature as well and that loss can be devastating to a young woman looking to having children or with young children at home [6, 7].

Patients who are facing the decision to undergo or who have had a mastectomy with reconstruction are then faced with feelings of anxiety, confusion, fear, and often depression. The loss of a breast can leave a woman feeling that they will never be seen as beautiful again. If they are unmarried they might feel that they will never find a husband, get married, and have children as they had hoped. Those with spouses or significant others may feel that they will be viewed as unattractive and untouchable and continue the spiral into a lack of desire for intimacy. In addition, for the many woman whom anti-estrogen therapies are recommended, they may suffer from side effects that further decrease their libido and may actually make intimacy painful. Pre-operative, post-operative, and survivorship resources should be offered in counseling, psychological therapy, support groups, and management of treatment related side effects to ease the journey [6, 7].

6. Conclusion

The journey for the patient with a breast related concern or breast cancer that includes breast reconstruction is one that is delicate to navigate. The path forward must be directed by that individual as it is a very personal one. Though they may have many care givers, family members, and/or friends who are full of opinions, only the individual involved can even begin to fathom how the outcome will affect them emotionally and physically. It is the job of the physician to discuss as clearly as possible all the options available to the patient and all the potential risks and benefits of the paths they might choose. They must establish clear expectations as to what the pre and post-operative outcomes may look like. It is also important that the physician and institution of which they are apart work to provide all the resources that a patient may need to face all aspects of their care, even if it is simply additional time to process all that is happening.

The ramifications of the decisions these patients make extend throughout the remainder of their lives. The surgery that the patient undergoes will forever alter how their breast care will be provided, the ability of the breast care team to provide breast imaging, their breast exam, and their options for breast cancer surveillance. It is also worthy of reiterating that no surgery is without a risk of requiring additional surgery and this idea must be explored. The short term and long term complications of surgical intervention are significant as well and must be acknowledged, as should their risk for breast cancer development prior to surgery.

Beyond the immediately pre and postoperative changes noted after a patient undergoes breast reconstruction, the breast patient who undergoes mastectomy with reconstruction for breast cancer may necessitate some additional attention. The breast cancer survivor after mastectomy with reconstruction has increased physical and psychosocial needs related to treatment. Local treatments like radiation can increase the complication rates noted after reconstruction as well as increasing the risk of lymphedema associated with axillary surgery. Post-surgical range of motion may be an issue necessitating a physical therapy referral. Pain management may also need to be addressed.

The emotional component of breast cancer surgery should also be reemphasized as it is often under-appreciated and overlooked. Support groups, counseling services, psychological services should all be used as appropriate to ensure the mental health of the patient. Distress screening to evaluate for issues concerning to the patient should also be performed at regular intervals to ensure the patient’s needs have not changed from prior discussions. Side effects related to systemic therapy should routinely be evaluated and treated as appropriate as they may have implications in regard to the emotional as well as physical components of their care.

Notably, in this setting surgical intervention does not only affect the individual it also can alter their relationships with others. The loss of a breast, no matter how cosmetically pleasing the outcome, alters the patient’s self-image and with that their ability to feel like the whole and beautiful woman that they are. Their friends, family, and significant others are sure to see this in the way they relate to them; especially as far as moments of intimacy with their romantic partners. Relationship counseling or marriage counseling is an option that can be explored in this particular setting.

The surgical oncologist as well as the plastic surgeon and the remaining breast care team should strive to provide truly holistic care for their patients that takes all of the aforementioned points into consideration. All these concerns should be brought up and addressed at the earliest point possible to ensure the best physical and emotional outcome for the individual involved. Referrals should be made to appropriate team members if a patient’s needs fall outside a particular area of expertise. The person as a whole must be incorporated into their care with their unique personality and goals of care taken into consideration; as it is only when we look at all aspects of an individual’s needs that we can then provide the care that they deserve.

Acknowledgments

I would like to acknowledge and express my gratitude to all the mentors who contributed to my training and my patients who allowed me to care for them.

Conflict of interest

I have no conflicts of interest beyond the fact that my perspective may be biased as I am approaching this topic from the perspective of a breast surgical oncologist.