"Now we start talking around the time of a patient's diagnosis," he says. "Women can choose from so many options. In the last few years, more general surgeons are willing to perform skin and nipple-sparing mastectomies, he notes. This yields better cosmetic results.
Still, the data suggest that only three in seven women get the chance to learn about reconstruction before they begin cancer treatment, Erhardt says. "In the old days, the general surgeons had the attitude that if they're saving a woman's life, she should be happy and not worry about anything else."
"Every woman needs the choice," Erhardt says. Still, it's probably not the right thing for every patient: "It's additional surgery; it's additional time off; it's additional expenses." These all factor in. Reconstruction may not be suitable for some women with other illnesses. "And I've seen some patients who, despite getting a good reconstruction, have never been able to get over the loss of their breast, or having had cancer," he says.
More often than not, Erhardt sees positive outcomes: "Reconstruction provides simplicity in women's lives," he says. After breast cancer, patients don't have to put on a body part every day, and they enjoy greater freedom in clothing. The benefits don't only apply to younger women. "From grandmothers, the constant thing I hear is that they don't want to worry about the prosthesis. They're with grandchildren at the beach, and if the prosthesis gets knocked out by a wave they're embarrassed."
The issue goes beyond convenience, he suggests. "It's about closure."
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Plastic surgery's not for everyone, says Dr. Costanza Cocilovo, a breast surgeon at Georgetown University. She estimates that one in five patients in her practice would prefer not to have the extra surgery. But for women who don't undergo reconstruction, the options are slim: "The standard prosthesis that Medicare will pay for is really horrible," she says. "It can be very upsetting, especially for older women if they've had a mastectomy on one side. They find it very difficult and embarrassing, because the alternatives are so unappealing."
A woman with a breast cancer diagnosis faces many sudden choices. Deciding whether to have a lumpectomy or mastectomy, and then choosing among oncologists and treatments -- chemotherapy, radiation, antibody infusions and possibly participating in a clinical trial -- involves a deluge of information.
In the frenzied and emotionally-loaded period of a new illness needing treatment, the decision on reconstruction may get short shrift, says Dr. Susan Cassidy, a physician and lawyer who has served as CEO of Contour Med, a manufacturer in Little Rock. Because insurance, by law, covers the costs of plastic surgery, and doctors in well-served communities tend to promote the procedure, breast cancer patients may not take sufficient pause to adequately contemplate the risks and benefits. "A woman should be informed about all the options, including custom prostheses," Cassidy says.
Whether she decides on implants, saline or silicone, or to have a TRAM-flap or other grafting procedure, the decision should be active, and considered. With knowledge in hand, she might move forward with reconstruction, knowingly and eagerly, or choose to hold off, entirely. It's a matter of choice.
Images: 1. Wearing a breast prosthesis/New Attitude; 2. Custom breast prostheses/New Attitude.