For Sarah Michaelis, waiting two years for a new breast was almost as agonizing as cancer itself.
The Toronto television producer was 36, and had only recently weaned her youngest daughter, when doctors told her in June of 2011 that the 10-centimetre lump in her chest was cancerous. Her left breast had to go.
"I didn't feel like a woman any more," she recalled, her voice wavering. "I'm going to cry, but it's true. You're bald and when you get out of surgery you don't realize how flat it is, but it's flat. There's nothing there."
Ms. Michaelis had to undergo chemotherapy and radiation first, but when she was ready six months later for breast reconstruction surgery, the health-care system was not ready for her. She waited nearly a year and a half more for a surgery slot. She figures it would have taken even longer if she had not broken down bawling in her oncologist's office.
All across Canada, hospitals are struggling to reduce waiting times and to increase the quality of care for women like Ms. Michaelis who want to have their breasts reconstructed after a mastectomy.
The procedure is growing in popularity as doctors and breast-cancer advocacy groups make a concerted effort to tell cancer survivors that they have publicly-funded plastic surgery options after their treatment is finished, and as more women who test positive for a gene mutation that increases their cancer risk ask doctors to remove and rebuild their breasts in a single operation.
The wait times for breast reconstruction in Canada range from as few as six weeks to as long as five years, depending on the hospital and the complexity of the operation, say plastic surgeons and provincial health ministries that try to measure the queues.
"We're at capacity with the resources that we have," said Sheina Macadam, a Vancouver plastic surgeon who specializes in breast reconstructions. "In order to get more patients in to surgery we need two things: We need dedicated operative time and we need [more] surgeons to do the surgery."
Dr. Macadam said women wait about a year to see her for a consultation. After that, cancer survivors who are seeking a delayed reconstruction wait anywhere from one to five years for their operations, depending on whether they choose implants or a more time-consuming procedure that sees fat siphoned from elsewhere on their bodies and moulded into new breasts.
High-risk women who do not have cancer but are seeking a prophylactic mastectomy with reconstruction – the procedure that the actress Angelina Jolie underwent in 2013 – wait one to two years, Dr. Macadam added.
It is difficult to say how many high-risk women develop cancer while waiting in line.
Dr. Macadam, in partnership with the B.C. Cancer Agency's hereditary cancer program, is in the midst of a study reviewing the cases of all women in the province who tested positive for mutations on their BRCA1 or BRCA2 genes between 2000 and 2012. Those genes, when they work properly, help suppress tumour growth.
Dr. Macadam's results are preliminary, but so far her study has found six women who developed breast cancer while waiting for mastectomies with reconstruction that would have reduced their risk.
"Clearly, that's very distressing," Dr. Macadam said.
In an unrelated study, Rethink Breast Cancer, an advocacy group for young women diagnosed with the disease, found two of the 49 Ontario breast-cancer patients or BRCA gene-mutation carriers they surveyed in late 2014 and early 2015 developed cancer while waiting for risk-reducing surgery. The survey also found the women waited about a year from the time they were referred to a plastic surgeon to their surgery in Ontario. (The Rethink survey, carried out by Environics Research Group, was funded in part by Allergan Canada, which makes devices used in breast reconstruction.)
Rethink Breast Cancer helped convince the Ontario government and Cancer Care Ontario to set up an expert panel on breast reconstruction practices in the province more than three years ago.
Cancer Care Ontario adopted some of the panel's recommendations on April 1, including more detailed tracking of prophylactic mastectomies with immediate reconstruction and a change to the way the government passes on funding to hospitals for breast reconstructions that is likely to reduce wait times and increase quality.
"We were probably on the underperformance curve for this group of patients. We need to do better," said John Irish, Cancer Care Ontario's clinical leader for access to services and wait times.
Toni Zhong, the clinical and research director of breast reconstruction at University Health Network and the head of Cancer Care Ontario's expert panel, said part of the challenge with immediate reconstructions is co-ordinating the schedules of general surgeons who remove the breasts, and the plastic surgeons who rebuild them, both of whom need to share their precious operating-room time.
"That's one enormous barrier with immediate reconstruction" said Dr. Zhong, who co-authored a 2015 study published in the World Journal of Surgery that found massive geographic disparities in breast reconstruction rates across Ontario. "It's very, very challenging when you have two different surgeons who have totally different practices."
Ed Buchel, the chair of plastic surgeon at the University of Manitoba, says his province has solved that dilemma.
Manitoba has set aside dedicated operating-room time for breast reconstructions so that general surgeons and plastic surgeons do not wind up sacrificing any of their own scarce operating room time to each other.
Waiting times for immediate reconstruction in Winnipeg – the only city in the province that offers the procedure – is less than six weeks. For delayed reconstructions, it's up to six months, depending on the woman's timing preference, Dr. Buchel said.
Ms. Michaelis said such a speedy trip to the operating room would have made it much easier to get back to feeling like herself after surviving cancer. Today, she is a healthy mother of two girls, 21 and 7, and she has just started her own production company.
"As much as we don't like to talk about sexuality and cancer together, it is a huge part of it, at least it was for me," she said. "You kind of want some level of normal back, and that was it for me."