Building the roads to recovery

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For women with breast cancer, having options for breast reconstruction is empowering

Lori Anne Hatch was just 31 when, while doing a self-examination, she discovered a lump in her left breast. "I didn't have a family doctor, so I went to the walk-in clinic, and a mammogram and ultrasound came back showing complications," she says. The lump turned out to be a rapidly growing and particularly aggressive cancer.

The Pickering, Ont., single mother and paralegal was promptly directed to a hospital for treatment, but after researching her options, chose to have her breast cancer care at Sunnybrook's Louise Temerty Breast Cancer Centre – part of the Odette Cancer Centre – which offers a leading breast reconstruction program.

"Breast reconstruction is an essential component of our care at Sunnybrook; we're very fortunate to have [our doctors] provide this next step in recovery," says psychologist Dr. Karen Fergus, a member of the Patient and Family Support Program at Odette and associate professor in the Department of Psychology at York University. "With reconstruction, it's no longer about treating the disease, but part of the process of recovering, helping [patients] move forward … It often represents the last step in the recovery process and helps them re-establish themselves."

Lori Anne Hatch, pictured with daughter Layla: "For my emotional well-being … I wanted to do [breast reconstruction] immediately."
PHOTOGRAPH: TIM FRASER

The Louise Temerty Breast Cancer Centre is a national leader in immediate breast reconstruction and offers this option to eligible patients undergoing a mastectomy or complex lumpectomy. Dr. Joan Lipa and Dr. Laura Snell developed the Breast Reconstruction and Oncologic Reconstructive Service and Research Group at Sunnybrook,which provides this option through a co-ordinated team effort with surgical oncologists Dr. Frances Wright, Dr. Claire Holloway and Dr. Nicole Look Hong at the Odette Cancer Centre program.

Lori Anne opted for immediate breast reconstruction. "I felt for my emotional well-being and the way I wanted to recover; I wanted to do [breast reconstruction] immediately," says Lori Anne of the procedure that sees patients undergo breast reconstruction at the same time as they undergo surgery to remove the cancer. Using the latest reconstruction techniques (see sidebar), the centre's expert plastic surgeons work closely with breast cancer surgeons leading up to and on the day of surgery.

For many women, the benefits of immediate reconstruction outweigh the possibility of additional surgeries and risks. "With immediate reconstruction, you don't have that loss in psychosexual well-being," says Dr. Lipa.

Lori Anne underwent chemotherapy before surgery, to reduce the size of the tumour. The cancer was aggressive and another tumour developed – in the same breast. For surgery, she opted for a double mastectomy and reconstruction using her own tissue rather than implants.

"I was excited to do that procedure because I had read that people can have issues with implants, especially because I had to do radiation after surgery [implants can develop scar tissue around them after radiation]," says Lori Anne, who notes that implants may also have to be maintained or replaced.

During the 12.5-hour surgery, Dr. Frances Wright, Lori Anne's surgical oncologist, removed the cancer in the left breast and surrounding breast tissue and also removed the right breast, while Dr. Lipa used tissue from the abdomen to reconstruct the breast areas. Lori Anne had the surgery in January 2014 and is waiting for two follow-up surgeries to enhance the appearance of areas on the breasts and abdomen.

Surgical oncologist Dr. Frances Wright is part of the core team at the Louise Temerty Breast Cancer Centre.
PHOTOGRAPH: DOUG NICHOLSON

"It was a long, painful recovery," admits Lori Anne, who notes it's important to do research beforehand and be active in the decision-making process, as well as to manage your and everyone else's expectations and create a close support system of family and friends.

"Allow and even request that family and friends support you; sometimes people don't know you need help unless you ask for it," says Lori Anne.

At the Odette Cancer Centre, psychosocial oncology professionals work with patients trying to cope with body image issues and provide a discreet and supportive forum for help. "For each woman herself, it's a major loss; I try to acknowledge that," says Dr. Fergus. "It takes a toll on her sense of self and sexual identity. I try to validate that [and] give them permission to grieve that loss."

Dr. Fergus notes that young women, in particular, may be more likely to undergo breast reconstruction. "For some women, breast reconstruction feels like a last step; for others they can put this behind them without it. [They] just want to get rid of cancer – and breast reconstruction is not really a priority for them," says Dr. Fergus.

"It's really important to have that option [breast reconstruction], though not all elect to," says Dr. Fergus, who emphasizes that "it's a commitment," with additional surgery and time for women who have already been through so much.

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Diane Tull, a Toronto-based engineer, is one patient who declined to have breast reconstruction when she had bilateral mastectomies. She was diagnosed with breast cancer in her right breast at age 36 and was at high risk of cancer developing in the other breast. "After eight rounds of chemotherapy, two surgeries and 27 rounds of radiation, I did not want to deal with breast cancer again," says Diane. "I opted out of the breast reconstruction program because I did not want to put my body through any additional stress. My breast does not define me."

For women who choose not to have reconstruction, Dr. Lipa says, "they're fine, if that is their choice; they are happy to have had the cancer dealt with and they get on with their lives that way. It's a completely individual decision."

While Diane did not opt for reconstruction, just having the choice is important, says Dr. Fergus. "[Breast reconstruction is] a choice; the benefits of having a choice are empowering," says Dr. Fergus.

As for Lori Anne, she's happy with the choice she made to have her breasts reconstructed. "They've healed very well and look and feel natural," says Lori Anne. "I think long term I'm going to be very happy with the decision I made and the reconstruction I got." 

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PHOTOGRAPH: TIM FRASER

HOW RECONSTRUCTION IS DONE

According to Dr. Joan Lipa (above), there are two general types of breast reconstruction options: breast implant-based and tissue-based.

For the implant-based, Dr. Lipa explains that a temporary stretching device is put in under the muscle and remaining skin on the chest wall, to first gradually expand the skin and muscle. The patient then returns to the operating room to have the permanent implant placed under the muscle.

For tissue-based breast reconstruction, explains Dr. Lipa, extra tissue is removed from the tummy area and used to reconstruct the breast. She says it results in a longer, higher scar than a tummy tuck and can take two to three months of recovery compared to six to eight weeks for implant-based surgery. Thanks to the latest DIEP (deep inferior epigastric perforator artery) Flap technique, the abdominal muscle can be spared. "It's done more and more at hospitals, but generally at larger centres," says Dr. Lipa.

At Sunnybrook, there's now the option to do immediate breast reconstruction, where breast cancer surgery and reconstruction can take place at the same time. "From a surgical standpoint", says Dr. Lipa, "with immediate reconstruction, you're filling up the breast [skin that remains]."

"It can look like a natural result," says Dr. Lipa, who adds that sometimes the mastectomy can be done to spare the nipple while with delayed reconstruction, the nipple generally can't be spared and more of the skin is removed, so both have to be replaced during the later reconstruction.

In the case of immediate reconstruction using breast implants, or "direct-to-implant" reconstruction that selected patients can choose to have, doctors put in the implant right away, but add in a tissue  scaffold called a cellular dermal matrix – for more support, explains Dr. Lipa. It can speed up recovery and doesn't require a stretching device or another surgery.

While other breast reconstruction options and combinations exist, treatment is assessed on an individual basis. The decision will depend on the woman's choice, but also on factors such as whether she will require chemotherapy or radiation treatment or whether she has enough extra tissue in her tummy area. According to Dr. Lipa, tissue and radiation work better together than implants and radiation do, though tissue-based reconstruction might shrink a little bit or might turn a little bit firmer. "Most candidates for immediate reconstruction are those who we don't think will need radiation treatment."

Lifestyle factors may come into play, too. Women with young children may not be able to undergo the DIEP Flap surgery as they would have to avoid heavy lifting for the three months of recovery, notes Dr. Lipa. In this case, she says, the patient may choose an implant-based reconstruction. •

This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.